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College  of  iPfegtciang  anb  burgeons; 
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MANUALS 


FOR 


Students  of  Medicine 


SURGICAL     APPLIED 
ANATOMY.     By    SIR 

FREDERICK    TREVES,   Bart., 

G.C.V.O.,  C.B.,  LL.D.,  F.R.C.S.  Sergeant 
Surgeon-in-Ordinary  to  H.M.  the  King  ; 
Surgeon-in-Ordinary  to  H.R.H.  the  Prince 
of  Wales  ;  Consulting  Surgeon  to  the  London 
Hospital  ;  Late  Lecturer  on  Anatomy  at  the 
London  Hospital 

Fifth   Edition,  Revised   by 

ARTHUR    KEITH,  m.d.,  f.r.c.s. 

Lecturer  on  and  Senior  Demonstrator  of 
Anatomy  at  the  London  Hospital  ;  Examiner 
in  Anatomy,  Royal  College  of  Surgeons, 
England,  and  University  of  Leeds  ;  formerly 
Examiner  in  Universities  of  Aberdeen, 
Cambridge,  etc. 

ILLUSTRATED    WITH    IO7    FIGURES,   INCLUDING   4. 1    IN   COLOUR 


PHILADELPHIA 

LEA     BROTHERS     AND     CO. 


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PREFACE    TO    THE    FIFTH    EDITION 

In  the  present  edition  the  work  has  been  carefully 
revised  throughout ;  certain  sections  have  been 
rewritten,  and  much  new  matter  has  been  added. 
Every  effort  has  been  made  to  bring  each  chapter 
of  the  book  well  up  to  date.  Neither  pains  nor 
expense  has  been  spared  in  the  matter  of  illus- 
trations. Forty-three  figures  have  been  specially 
prepared  for  this  edition  ;  fifteen  of  the  former 
figures  have  been  redrawn,  and  colours  have  been 
freely  used  to  make  the  illustrations  more  effective. 
The  editor  is  indebted  to  Messrs.  S.  J.  A.  Beale 
and  E.  H.  Eainey  for  their  assistance  in  the 
preparation   of  this  edition. 

Arthur  Keith. 

London  Hospital  Medical  College, 
August,  1907. 


PEEFACE    TO    THE    FIRST    EDITION 

Applied  Anatomy  has,  I  imagine,  a  twofold  func- 
tion. On  the  one  hand  it  serves  to  give  a 
precise  basis  to  those  incidents  and  procedures  in 
practice  that  more  especially  involve  anatomical 
knowledge  ;  on  the  other  hand  it  endues  the  dull 
items  of  that  knowledge  with  meaning  and  interest 
by  the  aid  of  illustrations  drawn  from  common 
medical  and  surgical  experience.  In  this  latter 
aspect  it  bears  somewhat  the  same  relation  to 
Systematic  Anatomy  that  a  series  of  experiments 
in  Physics  bears  to  a  treatise  dealing  with  the 
bare   data  of  that  science. 

The  student  of  Human  Anatomy  has  often  a 
nebulous  notion  that  what  he  is  learning  will 
sometime  prove  of  service  to  him ;  and  may  be 
conscious  also  that  the  study  is  a  valuable,  if 
somewhat  unexciting,  mental  exercise.  Beyond 
these  impressions  he  must  regard  his  efforts  as 
concerned  merely  in  the  accumulation  of  a  number 
of  hard,  unassimilable  facts.  It  should  be  one 
object  of  Applied  Anatomy  to  invest  these  facts 
with  the  interest  derived  from  an  association  with 
the  circumstances  of  daily  life ;  it  should  make 
the  dry  bones  live. 

It  must  be  owned  also  that  all  details  in 
Anatomy  have  not  the  same  practical  value,  and 
that  the  memory  of  many  of  them  may  fade  with- 
out loss  to  the  competency  of  the  practitioner  in 
medicine  or  surgery.  It  should  be  one  other 
object,  therefore,  of  a  book  having  such  a  purpose 
as  the  present,  to  assist  the  student  in  judging 
of   the   comparative   value   of   the   matter   he   has 


x  PREFACE 

learnt ;  and  should  help  him,  when  his  recollection 
of  anatomical  facts  grows  dim,  to  encourage  the 
survival  of  the  fittest. 

In  writing  this  manual  I  have  endeavoured,  so 
far  as  the  space  at  my  command  would  permit, 
to  carry  out  the  objects  above  described ;  and 
while  I  believe  that  the  chief  matters  usually  dealt 
with  in  works  on  Surgical  Anatomy  have  not  been 
neglected,  I  have  nevertheless  tried  to  make  the 
principle  of  the  book  the  principle  that  under- 
lies Mr.  Hilton's  familiar  lectures  on  "  Rest  and 
Pain." 

I  have  assumed  that  the  reader  has  some  know- 
ledge of  Human  Anatomy,  and  have  not  entered, 
except  in  a  few  instances,  into  any  detailed 
anatomical  descriptions.  The  bare  accounts,  for 
example,  of  the  regions  concerned  in  Hernia  I 
have  left  to  the  systematic  treatises,  and  have 
dealt  only  with  the  bearings  of  the  anatomy  of  the 
parts  upon  the  circumstances  of  practice.  The 
limits  of  space  have  compelled  me  to  omit  all 
those  parts  of  the  "  Surgery  of  the  Arteries  "  that 
deal  with  ligature,  collateral  circulation,  abnor- 
malities, and  the  like.^  This  omission  I  do  not 
regret,  since  those  subjects  are  fully  treated  not 
only  in  works  on  operative  surgery,  but  also  in 
the  manuals  of  general  anatomy. 

The  book  is  intended  mainly  for  the  use  of 
students  preparing  for  their  final  examination  in 
surgery.  I  hope,  however,  that  it  will  be  of 
use  also  to  practitioners  whose  memory  of  their 
dissecting-room  work  is  growing  a  little  grey,  and 
who  would  wish  to  recall  such  anatomical  matters 
as  have  the  most  direct  bearing  upon  the  details 
of  practice.  Moreover,  it  is  possible  that  junior 
students  may  find  some  interest  in  the  volume, 
and  may  have  their  studies  rendered  more  in- 
telligent by  learning  how  anatomy  is  concerned 
in  actual  dealings  with  disease. 

Frederick  Treves. 
September,   1883. 


CONTENTS 


PART  I.— THE   HEAD   AND   NECK 


CHAPTER 

I.- 

PAGE 

—The  Scalp 1 

II.- 

—The  Bony  Vault  op  the  Cranium  .        .      17 

III.- 

—The  Cranial  Contents        ....      31 

IV.- 

V.- 

VI.- 

—The  ISTose  and  Nasal  Cavities  ...      94 

VIL- 

-The  Face Ill 

VIII.- 

—The  Mouth,  Tongue,  Palate,  and  Pharynx    137 

IX.- 

PART  II.— THE   THORAX 

X. — The  Thorax    ... 


195 


PART  m -THE   UPPER   EXTREMITY 
XI. — The  Region  of  the  Shoulder  . 

XII.— The  Arm 

XIII. — The  Region  op  the  Elbow 
XIV.— The  Forearm         .        .        .        .        . 
XV.  -The  Wrist  and  Hand         . 


214 
255 
263 

282 
290 


xii  CONTENTS 

PART  IV,— THE   ABDOMEN   AND   PELVIS 

CHAPTER  PAGS 

XVI. — The  Abdomen 321 

XVII. — The  Abdominal  Viscera      ....    358 
XVIII. — The  Pelvis  and -Perineum         .        .        .    424 

I 

PART  V—  THE   LOWER   EXTREMITY 

XIX. — The  Region  of  the  Hip     ....  478 

XX.— The  Thigh 5l| 

XXI. — The  Region  op  the  Knee  ....  523 

XXII.— The  Leg ■  .        .  550' 

i 

XXIII.— The  Ankle  and  Foot 561  \ 


PART  VI.-THE   SPINE 

XXIV.— The  Spine 600 

Index 623 


Surgical  Applied  Anatomy 


Part  I.— THE   HEAD   AND   NECK 

CHAPTER    I 

THE     SCALP 

The  soft  parts  covering:  the  vault  of  the 
skull  may  be  divided  into  five  layers  :  (1)  the 
skin,  (2)  the  subcutaneous  fatty  tissue,  (3)  the 
occipito-frontalis  muscle  and  its  aponeurosis,  (4) 
the  subaponeurotic  connective  tissue,  and  (5)  the 
pericranium.  It  is  convenient  to  consider  the 
term  "  scalp  "  as  limited  to  the  structure  formed 
by  the  union  of  the  first  three  layers  above  named 

The  skin  of  the  scalp  is  thicker  than  in  any 
other  part  of  the  body.  It  is  in  all  parts  in- 
timately adherent,  by  means  of  the  subcutaneous 
tissue,  to  the  aponeurosis  and  muscle  beneath  it, 
and,  from  this  adhesion,  it  follows  that  the  skin 
moves  in  all  movements  of  that  muscle.  The  sub- 
cutaneous tissue  is,  like  a  similar  tissue  in  the 
palm,  admirably  constructed  to  resist  pressure, 
being  composed  of  a  multitude  of  fibrous  bands 
enclosing  fat  lobules  in  more  or  less  isolated  spaces 
(Fig.  1,  b).  The  density  of  the  scalp  is  such,  that 
in  surface  inflammations,  such  as  cutaneous  ery- 
sipelas, it  is  unable  to  present  (except  in  a  very 
slight  degree)  two  conspicuous  features  of  such 
inflammations,  viz.  redness  and  swelling.  The  skin 

B 


SURGICAL    APPLIED    ANATOMY      LPart  I 


is  provided  with  a  great  number  of  sebaceous 
glands,  which  may  develop  into  cystic  tumours  or 
wens,  such  cysts  being  more  common  upon  the  scalp 
than  in  any  other  part  of  the  body.  Being  skin 
growths,  these  cysts,  even  when  large,  remain,  ex- 
cept in  rare  instances,   entirely  outside  the  apo- 


Fig.  1  —Diagram  showing  the  layers  of  the  scalp  and  membranes  of  the 
R  VJ;  *brain  in  section. 

a,  Skin;  U,  subcutaneous  tissue  with  bail'  roots  and  vessels;  c,  epicranium ; 
ii,  subaponeurotic  layer;  e,  pericranium;  /,  parietal  bone;  g,  dura  mater; 
/.-,  arachnoid  ;  I,  pia  mater ;  m,  cortex  ;  n,  in  subdural  space  near  a  Pacchionian 
body  projecting  within  the  superior  Longitudinal  sinus. 

neurosis,  and  can  therefore  be  removed  without 
risk  of  opening  up  the  area  of  loose  connective 
tissue  between  the  aponeurosis  and  the  peri- 
cranium. 

There  being  no  fatty  tissue  in  any  of  the  layers 
that  cover  the  bony  vault  save  in  the  subcutaneous 
layer,  it  happens  that  in  cases  of  obesity  the  scalp 


Chap.  I]  THE    SCALP  3 

undergoes  but  little  change,  the  fat  in  the  subcu- 
taneous tissue  being  limited  by  the  dense  fibrous 
structures  that  enclose  it.  For  the  same  reasons 
fatty  tumours  of  the^  scalp  are  very  rare.  The 
attachment  of  the  hairs  collectively  to  the  scalp 
is  so  strong  that  there  are  many  cases  where  the 
entire  weight  of  the  body  has  been  supported  by 
the  hair  of  the  scalp.  Agnew  records  the  case  of 
a  woman  whose  hair  became  entangled  in  the  re- 
volving shaft  of  a  machine.  The  hair  did  not  give 
way,  but  the  entire  scalp  was  torn  off  from  the 
skull.  The  patient  recovered.  I  have  seen  a  pre- 
cisely similar  case  in  a  girl  aged  13.  (Museum, 
R.  Coll.  Surgeons,  87  F.) 

The  dangerous  area  of  the  scalp. — Between 
the  aponeurosis  and  the  pericranium  is  an  exten- 
sive layer  of  loose  connective  tissue,  that  may,  for 
reasons  to  be  presently  given,  be  fairly  called  the 
dangerous  area  of  the  scalp  (Fig.  1,  d).  The 
mobility  of  the  scalp  depends  entirely  upon  the 
laxity  of  this  layer  of  tissue.  In  extensive  scalp 
wounds,  when  a  part  of  the  scalp  is  separated  in 
the  form  of  a  large  flap,  a  flap  that  may  hang 
down  and  cover  half  the  face,  it  is  the  very  loose- 
ness of  this  tissue  that  permits  such  separation. 
In  the  Indian  process  of  scalping,  a  taste  that  is 
becoming  one  of  the  past,  the  much-prized  piece 
of  skin  is  torn  from  the  skull  through  this  lax 
area  of  connective  tissue,  and,  were  there  no  such 
area,  scalping  would  be  an  operation  requiring 
some  time  and  art. 

The  exposure  of  the  skull  in  a  post-mortem 
examination  is  effected  bv  peeling  off  the  scalp 
along  this  layer  of  loose  tissue,  and  it  is  remark- 
able with  what  ease  the  skull  can  be  exposed  by 
this  manoeuvre.  Sutures  may  be  safely  applied 
to  adjust  scalp  wounds,  provided  they  are  not 
too  long  retained.  _  They  probablv  include  the 
aponeurosis,  and  if  long  retained  may  act  as 
setons  and  set  up  suppuration,  which  may  find 
its  way  into  the  loose  layer  beneath  the  aponeu- 
rosis. 


4  SUKGICAL    APPLIED    ANATOMY       [Part  I 

Wounds  of  the  sculp  never  gape,  unless  the 
wound  has  involved  the  scalp  muscle  or  its  apo- 
neurosis. When  this  structure  has  been  divided 
the  lax  layer  beyond  permits  of  great  separation  of 
the  edges  of  even  the  simplest  wounds.  In  uncom- 
plicated incised  wounds,  the  amount  of  gaping  of 
the  cut  depends  upon  the  action  of  the  occipito- 
frontalis  muscle.  Those  wounds  gape  the  most 
that  are  made  across  the  muscle  itself,  and  that  are 
transverse  to  the  direction  of  its  fibres,  while  those 
show  the  least  separation  that  involve  the  apo- 
neurosis and  are  made  in  an  antero-posterior 
direction.  The  mobility  of  the  scalp  is  more 
marked  in  the  young  than  in  the  old.  A  case 
recorded  by  Agnew  serves  in  a  strange  degree  to 
illustrate  this  fact  in  the  person  of  an  infant.  A 
midwife  attending  a  woman  in  labour  mistook 
the  scalp  of  the  infant  for  the  membranes,  and 
gashed  it  with  a  pair  of  scissors.  Labour  pains 
came  on  and  the  head  was  protruded  through  the 
scalp  wound,  so  that  the  whole  vault  of  the  skull 
was  peeled  like  an  orange.  The  scalp  being  firmly 
stretched  over  the  hard  cranium  beneath,  it  follows 
that  contused  wounds  often  appear  as  cleanly  cut 
as  are  those  that  have  been  made  by  an  incision. 
Such  wounds  may  be  compared  to  the  clean  cut 
that  may  be  made  in  a  kid  glove  when  it  is  tightly 
stretched  over  the  knuckles  and  those  parts  are 
sharply  rapped. 

The  scalp  is  extremely  vascular,  and  presents 
therefore  a  great  resistance  to  sloughing  and  gan- 
grenous conditions.  Large  flaps  of  a  lacerated 
scalp,  even  when  extensively  separated  and  almost 
cut  off  from  the  rest  of  the  head,  are  more  prone 
to  live  than  to  die.  A  like  flap  of  skin,  separated 
from  other  parts  of  the  surface,  would  most  prob- 
ably perish ;  but  the  scalp  has  this  advantage,  that 
the  vessels  run  practically  in  the  skin  itself,  or 
are,  at  least,  in  the  tissue  beyond  the  aponeurosis 
(Fig.  1).  Thus,  when  a  scalp  flap  is  torn  up,  it 
still  carries  with  it  a  very  copious  blood  supply. 
Bleeding  from  these  wounds  is  usually  very  free, 


Chap.  I]  THE    SCALP  o 

and  often  difficult  to  arrest.  This  depends  not 
so  much  upon  the  number  of  vessels  in  the  part  as 
upon  the  density  of  the  tissue  through  which  these 
vessels  run,  the  adherence  of  the  outer  arterial 
wall  to  the  scalp  structure,  and  the  inability, 
therefore,  of  the  artery  to  retract  properly  when 
divided. 

For  the  same  reason  it  is  almost  impossible  to 
pick  up  an  artery  divided  in  a  scalp  wound.  The 
bleeding  is  checked  by  a  hare-lip  pin  or  by  pres- 
sure. 

In  all  parts  of  the  body  where  a  dense  bone  is 
covered  by  a  comparatively  thin  layer  of  soft  tis- 
sues, sloughing  of  those  tissues  is  apt  to  be  in- 
duced by  long  and  severe  pressure.  The  scalp,  by 
its  vascularity,  is  saved  to  a  great  extent  from 
this  evil,  and  is  much  less  liable  to  slough  than 
are  the  soft  parts  covering  such  bones  as  the  con- 
dyles of  the  humerus  or  the  sacrum.  But  such  an 
effect  is  sometimes  produced,  as  in  a  case  I  saw, 
where  the  tissues  over  the  frontal  and  occipital 
regions  sloughed  from  the  continued  application 
of  a  tight  bandage  put  on  to  arrest  bleeding  from 
a  frontal  wound. 

The  pericranium  is  but  slightly  adherent  to 
the  bone,  except  at  the  sutures,  where  it  is  inti- 
mately united  (Fig.  1,  e).  In  lacerated  wounds 
this  membrane  can  be  readily  stripped  from  the 
skull,  and  often,  in  these  injuries,  extensive  tracts 
of  bone  are  laid  bare.  The  pericranium  differs 
somewhat  in  its  functions  from  the  periosteum 
that  covers  other  bones.  If  the  periosteum  be 
removed  to  any  extent  from  a  bone,  the  part  from 
whence  it  is  removed  will  very  probably  perish, 
and  necrosis  from  deficient  blood  supply  result. 
But  the  pericranium  may  be  stripped  off  a  con- 
siderable part  of  the  skull  vault  without  any 
necrosis,  save  perhaps  a  little  superficial  exfolia- 
tion, following  in  consequence.  This  is  explained 
by  the  fact  that  the  cranial  bones  derive  their 
blood  supply  mainly  from  the  dura  mater,  and  are 
therefore  to  a  considerable  extent  independent  of 


6  SURGICAL    APPLIED    ANATOMY       [Part  I 

the  pericranium.  A  like  independence  cannot  be 
claimed  for  the  periosteum  covering  other  bones, 
since  that  membrane  brings  to  the  part  it  covers 
a  very  copious  and  essential  contribution  to  its 
blood  supply.  This  disposition  of  the  pericran- 
ium is  also  well  illustrated  by  its  action  in  cases 
of  necrosis  of  the  cranial  bones.  In  necrosis  of  a 
long  bone,  the  separation  of  the  sequestrum  is 
attended  with  a  vigorous  periosteal  growth  of 
new  bone,  which  repairs  the  gap  left  after  the  re- 
moval of  such  sequestra.  In  necrosis  of  the  vault 
of  the  skull,  however,  no  new  bone  is  formed,  as 
a  rule,  and  the  gap  remains  unrepaired.  The 
general  indisposition  of  the  pericranium  to  form 
new  bone  in  other  circumstances  is  frequently 
illustrated. 

Abscesses  in  the  scalp  region  may  be  situated 
(1)  above  the  aponeurosis,  (2)  between  the  apo- 
neurosis and  the  pericranium,  and  (3)  beneath  the 
pericranium.  Abscesses  in  the  first  situation  must 
always  be  small  and  comparatively  insignificant, 
since  the  density  of  the  scalp  tissue  here  is  such 
that  suppuration  can  only  extend  with  the  great- 
est difficulty.  Suppuration,  however,  in  the 
second  situation  (in  the  loose  tissue  beneath  the 
aponeurosis)  may  prove  very  serious.  The  laxity 
of  this  tissue  offers  every  inducement  to  the  ab- 
scess to  extend  when  once  pus  has  found  its  way 
between  the  aponeurosis  and  the  pericranium. 
Suppuration  in  this  area  may  undermine  the  en- 
tire scalp,  which  in  severe  and  unrelieved  cases 
may  rest  upon  the  abscess  beneath  as  upon  a  kind 
of  water-bed.  As  in  scalp  wounds,  the  aponeu- 
rosis is  often  divided,  and  as  suppuration  may 
follow  the  injury,  it  will  be  seen  that  the  chief 
danger  of  those  lesions  depends  upon  the  spread- 
ing of  such  suppuration  to  the  area  of  lax  con- 
nective tissue  now  under  notice.  The  significance 
of  a  small  amount  of  bare  bone  in  a  scalp  wound 
is  not  so  much  that  evils  will  happen  to  the  bone, 
but  that  the  aponeurosis  has  been  certainly 
divided,    and    the    dangerous    area    of    the    scalp 


Chap.  I]  THE    SCALP  7 

opened  up.  Suppuration,  when  it  occurs  in  this 
area,  is  only  limited  by  the  attachments  of  the 
occipito-frontalis  muscle  and  its  aponeurosis,  and 
therefore  the  most  dependent  places  through  which 
pus  can  be  evacuated  are  along  a  line  drawn 
round  the  head,  commencing  in  front,  above  the 
eyebrow,  passing  at  the  side  a  little  above  the 
zygoma,  and  ending  behind  at  the  superior  curved 
line  of  the  occipital  bone.  The  scalp,  even  when 
extensively  dissected  up  by  such  abscesses,  does 
not  perish,  since  it  carries,  as  above  explained,  its 
blood  supply  with  it.  The  abscess  is  often  very 
slow  to  close,  since  its  walls  are  prevented  from 
obtaining  perfect  rest  by  the  frequent  movement 
of  the  epicranial  muscle.  To  mitigate  this  evil, 
and  to  ensure  closing  of  the  sinuses  in  obstinate 
cases,  Mr.  Hilton  advises  that  the  whole  scalp  be 
firmly  secured  by  strapping,  so  that  the  movement 
of  the  muscle  is  arrested. 

Abscesses  beneath  the  pericranium  must  be 
limited  to  one  bone,  since  the  dipping  in  of  the 
membrane  at  the  sutures  prevents  a  more  exten- 
sive spreading  of  the  suppuration. 

Hseuiatoumta,  or  1>iood  tumours  of  the 
scalp  region,  occur  in  the  same  localities  as  ab- 
scesses. The  extravasation  of  blood  above  the  apo- 
neurosis must  be  of  a  limited  character,  while  that 
beneath  it  may  be  very  extensive.  It  fortunately 
happens,  however,  that  the  cellular  tissue  between 
the  aponeurosis  and  the  pericranium  contains  but 
very  few  vessels,  and  hence  large  extravasations  in 
this  tissue  are  uncommon. 

Extravasations  of  blood  beneath  the  peri- 
cranium are  generally  termed  cephalhsematomata, 
and  are  of  necessity  limited  to  one  bone.  They 
are  usually  congenital,  are  due  to  pressure  upon 
the  head  at  birth,  and  are  thus  most  commonly 
found  over  one  parietal  bone,  that  bone  being 
probably  the  one  most  exposed  to  pressure.  Their 
greater  frequency  in  male  children  may  depend 
upon  the  larger  size  of  the  head  in  the  male  fcetus. 
Such  extravasations  in  early  life  are  encouraged 


8  SUEGICAL   APPLIED    ANATOMY       [Part  I 

by  the  laxity  of  the  pericranium,  and  by  the  soft- 
ness and  vascularity  of  the  subjacent  bone. 

In  the  temporal  region,  or  the  region  corre- 
sponding to  the  temporal  muscle,  the  layers  of  soft 
parts  between  the  skin  and  the  bone  are  somewhat 
different  from  those  that  have  been  already  de- 
scribed as  common  to  the  chief  parts  of  the  scalp. 
There  is  a  good  deal  of  fat  in  the  temporal  fossa, 
and  when  this  is  absorbed  it  leads  to  more  or  less 
prominence  of  the  zygoma  and  malar  bone,  and 
so  produces  the  projecting  "  cheek  bones  ;'  of  the 
emaciated.  The  temporal  muscle  above  the  zy- 
goma is  covered  in  by  a  very  dense  fascia,  the 
temporal  fascia,  which  is  attached  above  to  the 
temporal  ridge  on  the  frontal  and  parietal  bones, 
and  below  to  the  zygomatic  arch.  The  unyielding 
nature  of  this  fascia  is  well  illustrated  by  a 
case  recorded  by  Denonvilliers.  It  concerned  a 
woman  who  had  fallen  in  the  street,  and  was  ad- 
mitted into  hospital  with  a  deep  wound  in  the 
temporal  region.  A  piece  of  bone  of  several  lines 
in  length  was  found  loose  at  the  bottom  of  the 
wound,  and  was  removed.  After  its  removal  the 
finger  could  be  passed  through  an  opening  with 
an  unyielding  border,  and  came  in  contact  with 
some  soft  substance  beyond.  The  case  was  con- 
sidered to  be  one  of  compound  fracture  of  the 
squamous  bone,  with  separation  of  a  fragment 
and  exposure  of  the  brain.  A  bystander,  however, 
noticed  that  the  bone  removed  was  dry  and  white, 
and  a  more  complete  examination  of  the  wound 
revealed  the  fact  that  the  skull  was  uninjured, 
that  the  supposed  hole  in  the  skull  was  merely 
a  laceration  of  the  temporal  fascia,  that  the  soft 
matter  beyond  was  muscle  and  not  brain,  and  that 
the  fragment  removed  was  simply  a  piece  of  bone 
which,  lying  on  the  ground,  had  been  driven  into 
the  soft  parts  when  the  woman  fell. 

Abscesses  in  the  temporal  fossa  are  prevented 
by  the  fascia  from  opening  anywhere  above  the 
zygoma,  and  are  encouraged  rather  to  spread  into 
the  pterygoid  and  maxillary  regions  and  into  the  neck. 


Chap.  I] 


THE    SCALP 


The  pericranium  in  the  temporal  region  is 
much  more  adherent  to  the  bone  than  it- is  over 
the  rest  of  the  vault,  and  subpericranial  extrava- 
sations of  blood  are  therefore  practically  unknown 
in  this  part  of  the  cranial  wall. 

Trephining-.— This  operation  is  frequently  per- 
formed in  the  temporal  region,  its  object  being 
to  reach  extravasations  of  blood  from  the  middle 
meningeal    artery.     This    artery    crosses    the    an- 


DREq/^A 


Sup  .Tem.line 

Lambda 
Squamous  Suture 


POST.DlV.OFfllD.MEn.AR- 
AsTEP-ION 

SupraMeatalTriamcle 
Lateral  Sirtus 

IftIO 

Ext.  Auditory  /ieatus 
Occipital  Art 


IflT.  JUQULAR.   VEIM 


Ext.  Carotid  Art 


Fig.  2. — Points  to  trephine  for  middle  meningeal  artery  and  lateral  sinus- 

terior  inferior  angle  of  the  parietal  bone  at  a 
point  1|  inches  behind  the  external  angular  pro- 
cess of  the  frontal  bone,  and  l|  inches  above  the 
zygoma.  In  cutting  down  to  expose  this  artery 
the  following  structures  are  met  with  in  order  : 
(1)  The  skin;  (2)  branches  of  the  superficial  tem- 
poral vessels  and  nerves ;  (3)  the  fascia  continued 
down  from  the  epicranial  aponeurosis ;  (4)  the 
temporal  fascia;  (5)  the  temporal  muscle;  (6)  the 
deep  temporal  vessels;  (7)  the  pericranium;  (8) 
the  anterior  inferior  angle  of  the  parietal  bone. 


10  SURGICAL   APPLIED    ANATOMY       [Part  I 

Trephining  for  meningeal  licemorrhage  and 
cerebral  abscess. — At  the  anterior  inferior  angle 
of  the  parietal  bone  the  anterior  division  of  the 
middle  meningeal  artery  lies  with  its  companion 
veins  in  a  deep  groove  or  even  canal  in  the  bone. 
A  fracture  of  the  bone,  which  is  comparatively 
thin  in  the  region  of  the  pterion,  is  apt  to  involve 
the  artery,  leading  to  a  subdural  haemorrhage, 
with  consequent  compression  of  the  brain.  The 
pterion  lies  1\  inches  behind  and  |  inch  above 
the  notch  of  the  fronto-malar  suture— a  point 
which  can  be  readily  felt  (Fig.  2);  Similar  mea- 
surements— namely,  1\  inches  behind  and  \  inch 
above — taken  from  the  centre  of  the  external 
auditory  meatus — the  meatal  point,  gives  the  posi- 
tion of  the  posterior  inferior  angle  of  the  parietal 
bone  (asterion),  beneath  which  lies  the  highest 
point  of  the  lateral  sinus  (Fig.  2).  A  trephine 
opening,  f  inch  in  diameter,  made  over  the  as- 
terion, will  expose  the  lateral  sinus,  and  give 
access  to  the  temporo-sphenoidal  lobe  above  _  it 
and  the  cerebellum  below  it.  The  posterior 
division  of  the  middle  meningeal,  in  the  majority 
of  cases,  will  be  exposed  by  trephining  at  a  point 
1  inch  above  the  external  auditory  meatus.  These 
measurements  apply  to  the  head  of  the  average 
adult ;  allowance  must  be  made  for  youth  and  for 
the  size  and  shape  of  the  head.  In  finding  the 
pterion  the  line  is  drawn  backwards  parallel  to 
the  upper  border  of  the  zygoma;  in  finding  the 
asterion,  the  line  is  drawn  backwards  along  the 
meato-inionic  line  (Fig.  2),  which  passes  from  the 
centre  of  the  external  meatus  to  the  most  promi- 
nent point  of  the  external  occipital  protuberance 
—the  inion. 

Intracranial  abscess  is  often  due  to  middle-ear 
disease,  and  is  then  very  commonly  found  in  the 
temporo-sphenoidal.  lobe  or  in  the  cerebellum.  It 
is  estimated  to  be  three  times  more  common  in 
the  cerebrum  than  in  the  cerebellum. 

The  abscess  of  the  temporo-sphenoidal  lobe  is 
usually  found  in  that  part  of  the  lobe  which  lies 


Ohap.  I]  THE   SCALP  11 

over  the  tegmen  tympani — a  thin  plate  of  bone 
which  forms  the  roof  of  the  tympanum  and  of  the 
antrum  of  the  mastoid.  The  level  of  the  tegmen 
may  be  indicated  thus  (Fig.  3)  :  a  point  is  taken 
above  the  meatus  in  line  with  the  upper  border  of 
the  zygoma;  this  suprameatal  point  is  joined 
with  the  asterion,  which  lies,  it  will  be  remem- 
bered, 1^  inches  behind  and  ^  inch  above  the 
meatus ;  the  anterior  half  of  the  above  line  corre- 
sponds to  the  tegmen  tympani.  A  trephine  open- 
ing made  1  inch  above  the  level  of  the  tegmen  is 
the  most  likely  to  give  access  to  a  temporo- 
sphenoidal  abscess. 

In  dealing  with  an  abscess  of  the  cerebellum 
the  best  spot  to  select  is,  in  the  adult,  1^  inches 
behind  the  centre  of  the  meatus  and  \  inch  below 
the  meato-inionic  line. 

In  some  cases  it  is  impossible  to  say  whether  the 
abscess  is  situated  in  the  temporo-sphenoidal  lobe 
or  cerebellum.  In  such  cases  Mr.  Dean  trephines 
at  a  point  which  lies  l\  inches  behind  and  \  inch 
above  the  centre  of  the  meatus.  The  lateral  sinus 
is  thus  exposed  with  a  part  of  the  dura  mater 
above  the  tentorium  cerebelli,  through  which  the 
temporo-sphenoidal  lobe  may  be  explored.  By  ex- 
tending the  trephine  opening  \  inch  downwards 
the  cerebellum  may  be  examined. 

Trephining  for  cerebral  tumour. — The  position 
of  the  opening  in  the  skull  is  obviously  determined 
by  the  localising  symptoms.  It  is  remarkable  that 
little  trouble  from  haemorrhage  has  attended  these 
operations. 

In  any  case,  after  trephining,  the  portion  or 
portions  of  bone  removed  may — if  properly 
treated — be  replaced  in  the  opening,  and  will 
serve,  especially  in  youthful  subjects,  to  make 
good  the  gap  left  by  the  operation. 

In  trephining  the  skull  generally,  the  compara- 
tive thickness  of  the  cranial  wall  in  various  parts 
should  be  borne  in  mind  (p.  30),  and  the  large 
arteries  of  the  scalp  should  be  avoided  if  possible. 
In  order  to  accommodate  the  instrument  to  the 


12 


SURGICAL   APPLIED    ANATOMY       [Part  I 


varying  thickness  of  the  skull,  the  pin  of  the 
trephine  is  not  allowed  to  protrude  more  than 
iVth  of  an  inch.  The  trephine  should  not  be  ap- 
plied over  the  frontal  sinuses,  which  are  often 
of  large  size  in  the  aged,  and  should,  when  possi- 
ble, keep  clear  of  the  sutures,  owing  to  the  fre- 
quent exit  of  emissary  veins  at  or  about  suture 
lines.  The  bone,  moreover,  at  certain  of  these 
lines  is  of  unequal  thickness.  Between  the  bones 
forming  the  sutures  passes  the  sutural  membrane. 


Upper  Holamdic  Poi/it 


Fissure  of  Rolamdo 


Parietal  Eminence 

Parieto  Occipital  Fissure- 
Lambda 

For  Lateral  Ventricle 
Post.  Ior/i 
Desc.Morm 
For Temp.Sp/ien  Abscess 

Occipital  Pole 
Iaiion 


Asterion 
T)vi panic  Plate 
Suprameatal  Triadcle 
Meatus 
Supra/i eatal  Point  , 

Fig.  3. — Diagram  to  show  the  position  of  the  lateral  ventricles,  Island  of 
Reil  and  temporal  lobe. 

This  structure  blends  with  the  dura  mater,   and 
laceration  of  it  may  conduce  to  meningitis. 

The  zygoma  may  be  broken  by  direct  or  in- 
direct violence.  In  the  latter  case  the  violence  is 
such  as  tends  to  thrust  the  upper  jaw  or  malar 
bone  backwards.  When  due  to  direct  violence,  a 
fragment  may  be  driven  into  the  temporal  muscle, 
and  much  pain  caused  in  moving  the  jaw.  In 
ordinary  cases  there  is  little  or  no  displacement, 
since  to  both  fragments  the  temporal  fascia  is 
attached  above  and  the  masseter  below.  The  zy- 
goma serves  as  a  most  useful  guide  to  the  position 


Chap.  I]  THE    SCALP  13 

of  deep  parts.  Its  upper  border,  in  its  posterior 
three-fourths,  corresponds  to  the  floor  of  the  mid- 
dle fossa  of  the  skull,  and  marks  the  lower  border 
of  the  temporal  lobe  of  the  brain  which  lies  in 
that  fossa  (Fig.  3) ;  the  articular  eminence,  felt 
so  plainly  near  its  root,  marks  the  point  at  which 
the  middle  meningeal  artery _  perforates  the  base 
of  the  skull  by  the  foramen  spinosum  (Fig.  2),  and 
also  the  position  of  the  Gasserian  ganglion  (Fig. 
26,  p.  119) ;  the  post-glenoid  spine  is  directly  over 
the  carotid  canal  (S.  Scott). 

The  vessels  and  nerves  of  the  scalp.— The 
supraorbital  artery  and  nerve  pass  vertically  up- 
wards from  the  supraorbital  notch,  which  is  situ- 
ate at  the  junction  of  the  middle  with  the  inner 
third  of  the  upper  orbital  margin.  Nearer  the 
middle  line  the  frontal  artery  and  supratrochlear 
nerve  ascend.  This  artery  gives  life  to  the  flap 
that  in  rhinoplasty  is  taken  from  the  forehead 
to  form  a  new  nose.  The  temporal  artery,  with 
the  auriculotemporal  nerve  behind  it,  crosses  the 
base  of  the  zygoma  just  in  front  of  the  ear.  The 
vessel  divides  into  its  two  terminal  branches  (the 
anterior  and  posterior)  2  inches  above  the  zygoma. 
The  branches  of  this  artery,  especially  the  an- 
terior branch,  are  often  very  tortuous  in  the  aged, 
and  afford  early  evidence  of  arterial  degeneration. 
Arteriotomy  is  sometimes  practised  on  the  an- 
terior branch  of  this  vessel.  The  superficial  tem- 
poral vessels  are  very  liable  to  be  the  seat  of 
cirsoid  aneurism,  as,  to  a  less  extent,  are  the  other 
scalp  arteries.  Cirsoid  aneurism  is  more  often 
met  with  in  the  superficial  temporal  arteries  than 
in  any  other  artery  in  the  body.  The  posterior 
auricular  artery  and  nerve  run  in  the  groove  be- 
tween the  mastoid  process  and  the  ear,  and  the 
occipital  artery  and  great  occipital  nerve  reach 
the  scalp  just  internally  to  a  point  midway  be- 
tween the  occipital  protuberance  and  the  mastoid 
process. 

Certain  of  the  emissary  veins  are  of  import- 
ance in  surgery.     These  veins  pass  through  aper- 


14  SURGICAL    APPLIED    ANATOMY       [Part  J 

tures  in  the  cranial  wall,  and  establish  communi- 
cations between  the  venous  circulation  (the 
sinuses)  within  the  skull  and  the  superficial  veins 
external  to  it.  The  principal  emissary  veins  are 
the  following  :  1.  A  vein  passing  through  the  mas- 
toid foramen  and  connecting  _  the  lateral  sinus 
with  the  posterior  auricular  vein  or  with  an  occi- 
pital vein.  This  is  the  largest  and  most  constant 
of  the  series.  The  existence  of  this  mastoid  vein 
serves  to  answer  the  question,  Why  is  it  a  com- 
mon practice  to  apply  leeches  and  blisters  behind 
the  ear  in  certain  cerebral  affections  1  2.  A  vein 
connecting  the  superior  longitudinal  sinus  with 
the  veins  of  the  scalp  through  the  parietal  fora- 
men. 3.  A  vein  connecting  the  lateral  sinus  with 
the  deep  veins  at  the  back  of  the  neck  through  the 
posterior  condylar  foramen  (inconstant).  4. 
Minute  veins  following  the  twelfth  nerve  through 
its  foramen,  and  connecting  the  occipital  sinus 
with  the  deep  veins  of  the  neck.  5.  Minute  veins 
passing  through  the  foramen  ovale,  foramen  of 
Vesalius,  foramen  lacerum  medium,  and  carotid 
canal  to  connect  the  cavernous  sinus  with  (respec- 
tively) the  pterygoid  venous  plexus,  the  pharyn- 
geal plexus,  and  the  internal  jugular  vein. 

Then,  again,  many  minute  veins  connect  the 
veins  of  the  scalp  with  those  of  the  diploe.  Of  the 
four  diploic  veins,  two  (the  frontal  and  anterior 
temporal)  enter  into  surface  veins  (the  supra- 
orbital and  deep  temporal),  and  two  (the  pos- 
terior temporal  and  occipital)  enter  into  the 
lateral  sinus. 

Lastly,  there  is  the  well-known  communication 
between  the  extra-  and  intracranial  venous  circu- 
lation effected  by  the  commencement  of  the  facial 
vein  at  the  inner  angle  of  the  orbit.  In  this  com- 
munication the  angular  and  supraorbital  veins 
unite  with  the  superior  ophthalmic  vein,  a  tribu- 
tary of  the  cavernous  sinus.  The  veins  within  the 
cavities  of  the  nose  and  middle  ear  also  communi- 
cate with  those  of  the  meninges. 

Through  these  various  channels,   and  through 


Chap.  I] 


THE    SCALP 


15 


many  probably  still  less  conspicuous,  inflammatory 
processes  can  spread  from  the  surface  to  the  in- 
terior of  the  skull.    Thus  we  find  such  affections  as 


Nerve  areas  of  the  face  and  scalp. 


a,  a,  Distribution  of  the  first  division  of  the  fifth  cranial  nerve  :  a',  nasal  branch  ; 

a",  supratrochlear  ;  a'",  supraorbital, 
n,  b,  distribution  of  the  second  division ;  b',  infraorbital  branch  j  b",  malar  branch  ; 

b"',  temporal  branch. 
c,  c,  distribution  of  the  third  division ;  c',  mental  branch  ;  c",  buccal  branch  ;  c'", 

auriculo-temporal. 

1,  area  of  great  occipital;  2,  of  small  occipital;  3,  of  great  auricular;  4,  of 

superficial  cervical ;  .%  of  third  occipital. 

erysipelas  of  the  scalp,  diffuse  suppuration  of  the 
scalp,  necrosis  of  the  cranial  bones,  and  the  like, 
leading  by  extension  to  mischief  within  the  diploe, 
to  thrombosis  of  the  sinuses,  and  to  inflammation 


16  SUEGICAL    APPLIED    ANATOMY       [Part  I 

of  the  meninges  of  the  brain.  If  there  were  no 
emissary  veins,  injuries  and  diseases  of  the  scalp 
and  skull  would  lose  half  their  seriousness.  Mis- 
chief may  even  spread  from  within  outwards  along 
an  emissary  vein.  Erichsen  reports  a  case  where 
the  lateral  sinus  was  exposed  in  a  compound  frac- 
ture. The  aperture  was  plugged.  Thrombosis  and 
suppuration  within  the  sinus  followed,  and  some  of 
the  pus,  escaping  through  the  mastoid  vein,  led  to 
an  abscess  in  the  neck. 

Certain  venous  tumours  are  met  with  on  the 
skull.  They  consist  of  collections  of  venous  blood 
under  the  pericranium  that  communicate,  through 
holes  in  the  skull,  with  the  superior  longitudinal 
sinus.  They  are  median,  are  reducible  on  pressure, 
and  receive  a  faint  pulsation  from  the  brain.  The 
holes  are  sometimes  the  result  of  accident,  others 
depend  upon  bone  disease  or  atrophy  over  a  Pac- 
chionian body,  and  a  few  are  due  to -a  varicose 
emissary  vein  or  to  a  congenital  defect  in  the 
cranium,  especially  in  the  neighbourhood  of  the 
parietal  foramina. 

The  scalp  nerves,  especially  such  as  are  branches 
of  the  fifth  pair,  are  often  the  seat  of  neuralgia 
(Fig.  4).  To  relieve  one  form  of  this  affection,  the 
supraorbital  nerve  has  been  divided  (neurotomy) 
at  its  point  of  exit  from  the  orbit,  and  a  portion 
of  the  nerve  has  been  resected  (neurectomy)  in  the 
same  situation.  Some  forms  of  frontal  headache 
depend  upon  neuralgia  of  this  nerve.  The  inner 
branch  of  the  nerve  reaches  the  middle  of  the 
parietal  bone ;  the  outer  branch,  the  lambdoid 
suture. 

The  lymphatics  from  the  occipital  and  pos- 
terior parietal  regions  of  the  scalp  enter  the  oc- 
cipital and  mastoid  glands  ;  those  from  the  frontal 
and  anterior  parietal  regions  go  to  the  parotid 
glands,  while  some  of  the  vessels  from  the  frontal 
region  join  the  lymphatics  of  the  face  and  end  in 
the  submaxillary  glands  (Fig.  35,  p.  190). 


CHAPTER    II 

THE   BONY  VAULT  OF  THE  CRANIUM 

Position  of  the  sutures.  —  The  bregma,  or 
point  of  junction  of  the  coronal  and  sagittal 
sutures,  is  in  a  line  drawn  vertically  upwards  from 
a  point  just  in  front  of  the  external  auditory 
meatus,  the  head  being  in  normal  position  (Fig.  2). 
The  lambda,  or  point  of  junction  of  the  lambdoid 
and  sagittal  sutures,  lies  in  the  middle  line,  about 
2\  inches  above  the  occipital  protuberance  (Fig.  2). 
The  lambdoid  suture  is  fairly  represented  by  the 
upper  two-thirds  of  a  line  drawn  from  the  lambda 
to  the  apex  of  the  mastoid  process  on  either  side. 
The  coronal  suture  lies  along  a  line  drawn  from 
the  bregma  to  the  middle  of  the  zygomatic  arch. 
On  this  line,  at  a  spot  about  1^  inches  behind  and 
above  the  fronto-malar  junction,  is  the  pterion,  the 
region  where  four  bones  meet,  viz.  the  squamous 
bone,  the  great  wing  of  the  sphenoid,  the  frontal 
and  parietal  bones  (Fig.  2).  The  summit  of  the 
squamous  suture  is  If  inches  above  the  zygoma. 

In  the  normal  subject  all  traces  of  the  fon- 
tanelles  and  other  unossified  parts  of  the  skull 
disappear  before  the  age  of  two  years  (Fig.  6). 
The  anterior  fontanelle  is  the  last  to  close,  while 
the  posterior  is  already  filled  at  the  time  of 
birth.  It  is  through  or  about  the  anterior 
fontanelle  that  the  ventricles  are  usually  as- 
nirated  in  cases  of  hydrocephalus.  The  needle 
is  either  entered  at  the  sides  of  the  fontan- 
elle at  a  sufficient  distance  from  the  middle 
c  17 


18  SURGICAL   APPLIED    ANATOMY       [Part  I 

line  to  avoid  the  longitudinal  sinus,  or  is  intro- 
duced through  the  coronal  suture  at  some  spot 
other  than  its  middle  point.  It  may  be  noted  that 
in  severe  hydrocephalus  the  coronal  and  other 
sutures  of  the  vault  are  widely  opened. 

The  condition  known  as  cr»nio-tal>es,  a  con- 
dition assigned  by  some  to  rickets  and  by  others  to 
inherited  syphilis,  is  usually  met  with  in  the  verti- 
cal part  of  the  occipital  bone,  and  in  the  adjacent 
parts  of  the  parietal  bones,  but  especially  in  the 
posterior  inferior  angles  of  these  bones.  In  this 
condition  the  bone  is  greatly  thinned  in  spots,  and 
its  tissue  so  reduced  that  the  affected  district  feels 
to  the  finger  as  if  occupied  by  parchment,  or,  as 
some  suggest,  by  cartridge  paper.  The  thinning  is 
mainly  at  the  expense  of  the  inner  table  and  diploe. 
The  pits  are  situated  over  the  impressions  of  early 
formed  convolutions.  It  is,  on  the  other  hand, 
about  the  site  of  the  anterior  fontanelle  that  cer- 
tain osseous  deposits  are  met  with  on  the  surface 
of  the  skull  in  some  cases  of  hereditary  syphilis 
(Parrot).  These  deposits  appear  as  rounded  ele- 
vations of  porous  bone  situated  upon  the  frontal 
and  parietal  bones,  where  they  meet  in  the  middle 
line.  These  bosses  are  separated  by  a  crucial  de- 
pression represented  by  the  frontal  and  sagittal 
sutures  on  the  one  hand  and  the  coronal  suture  on 
the  other.  They  have  been  termed  "  natiform  " 
elevations  by  M.  Parrot  from  their  supposed  resem- 
blance, when  viewed  collectively,  to  the  nates.  To 
the-  English  mind  they  would  rather  suggest  the 
outlines  of  a  "hot-cross  bun." 

It  is  necessary  to  refer  to  the  development  ol 
the  skull  in  order  to  render  intelligible  certain 
conditions  (for  the  most  part  those  of  congenital 
malformation)  that  are  not  unfrequently  met  with. 
Speaking  generally,  it  may  be  said  that  the  base  of 
the  skull  is  developed  in  cartilage,  and  the  vault 
in  membrane.  The  parts  actually  formed  in  mem- 
brane are  represented  in  the  completed  skull  by 
the  frontal  and  parietal  bones,  the  squamo-zygo- 
matic  part  of  the  temporal  bone,  and  the  greater 


Chap.  Ill    THE   VAULT   OF   THE  CRANIUM 


19 


part  of  the  expanded  portion  of  the  occipital  bone. 
The  distinction  between  these  two  parts  of  the 
skull  is  often  rendered  very  marked  by  disease. 
Thus  there  are,  in  the  museum  of  the  Royal  College 
of  Surgeons,  the  skulls  of  some  young  lions  that 
were  born  in  a  menagerie,  and  that,  in  consequence 
of  malnutrition,  developed  certain  changes  in 
their  bones.  A  great  part_  of  each  of  these  skulls 
shows  considerable  thickening,  the  bone  being  con- 
verted into  a  porous  structure  ;  and  it  is  remark- 
able to  note  that  these  changes  are  limited  to  such 
parts  of  the  skull  as  are  formed  in  membrane,  the 
base  remaining  free.  In  hydrocephaly  and  in  the 
condition  known  as  achondroplasia,  it  is  only  the 
bones  formed  in  membrane  which  are  unduly  ex- 
panded. 

Among  the  more  common  of  the  gross  malforma- 
tions of  the  skull  also  is  one  that  shows  entire  ab- 
sence of  all  that  part  of  the  cranium  that  is  formed 
in  membrane,  while  the  base,  or  cartilaginous  part, 
is  more  or  less  perfectly  developed — the  condition 
of  anencephaly. 

Meningocele  is  the  name  given  to  a  con- 
genital tumour  that  consists  of  a  protrusion  of  a 
part  of  the  cerebral  mem- 
branes through  a  gap  in  an 
imperfectly  developed  skull. 
When  the  protrusion  contains 
brain,  it  is  called  an  encepha- 
locele,  and  wrhen  that  pro- 
truded brain  is  distended  by 
an  accumulation  of  fluid  with- 
in the  ventricles,  it  is  called 
hydrencephalocele.  These  pro- 
trusions are  most  often  met 
with  in  the  occipital  bone, 
and  next  in  frequency  in  the 
f ronto-nasal  suture,  while  in 
rarer  cases  they  have  been 
met  with  in  the  lambdoid, 
sagittal,  and  other  sutures,  and  have  projected 
through    normal    and    abnormal    fissures    at    the 


Fig.  5. — The  occipital 
bone  at  birth. 


20 


SURGICAL   APPLIED    ANATOMY       [Part  I 


base  of  the  skull  into  the  orbit,  nose,  and 
mouth.  Their  frequency  in  the  occipital  bone 
may  be  in  some  degree  explained  by  a  refer- 
ence to  the  development  of  that  part.  This 
bone  at  birth  consists  of  four  separate  parts 
(Fig.  5),  a  basilar,  two  condylar,  and  a  tabular 
or  expanded  part.  In  the  tabular  part,  about 
the  seventh  week  of  foetal  life  four  nuclei  appear, 
an  upper  and  a  lower  pair.  These  nuclei  are 
to  some  extent  separated  by  fissures  running 
inwards  from  the  four  angles  of  the  bone  to  meet 


/ietopic  Suture 
.Frontal  Eminence 


...BReqmatic  Fontanelle 
...Coronal  suture 

.SAqiTTAL  5UTURE 


-Parietal  Eminence 
Sagittal  Fontanelle 


LambdoidalFo/uahelle 

Inter  Parietal 

Supra  Occipital 


Fig.  6.—  Skull  of  newly  born  child  from  above. 

at  the  occipital  protuberance.  The  gap  running 
up  in  the  median  line  from  the  inferior  angle  at 
the  foramen  magnum  to  the  occipital  protuberance 
is  especially  distinct  (the  temporary  occipital 
fontanelle  of  Sutton).  It  exists  from  the  beginning 
of  the  third  to  the  end  of  the  fourth  month  of 
intrauterine  life.  Meningoceles  of  the  occiput 
are  always  in  the  middle  line,  and  the  protrusion 
probably  occurs  through  this  gap.  The  gap  associ- 
ated with  meningocele  may  extend  through  the 
whole  vertical  length  of  the  occipital  bone,  and 
very  commonly  opens  up  the  foramen  magnum. 
The  lateral  or  transverse  fissures  divide  the  bone 
into  two  parts.    The  upper  part  is  developed  from 


Chap.  II]    THE   VAULT   OF   THE  CRANIUM  21 

membrane,  the  lower  part  from  cartilage.  The 
lateral  fissures  may  persist,  and  may  simulate  frac- 
tures, for  which  they  have,  indeed,  been  mistaken  ; 
or  they  may  be  so  complete  as  entirely  to  separ- 
ate the  highest  part  of  the  occipital  bone  from  the 
remainder.  The  bone  so  separated  is  the  os  epactal 
of  the  French,  the  interparietal  bone  of  some 
animals  (Fig.  6). 

Parietal  fissures. — In  the  developing  parie- 
tal bone,  fibres  concerned  in  ossification  radiate 
towards  the  periphery  from  two  nuclei  about  the 
centre  of  the  bone.  An  interfibrillar  space,  larger 
than  the  rest,  is  seen  about  the  fifth  month,  to 
separate  the  loose  osseous  fibres  which  abut  on  the 
posterior  part  of  the  sagittal  border  from  the 
stronger  fibres  which  form  the  rest  of  this  border 
(Pozzi).  This  is  the  parietal  fissure  (Fig.  6).  It 
usually  closes  and  leaves  no  trace,  but  it  may  per- 
sist in  part  as  a  suture-like  fissure,  and  be  mistaken 
for  a  fracture.  If  the  fissure  persists  equally  on 
the  two  sides  an  elongated  lozenge-shaped  gap  is 
left,  the  sagittal  fontanelle  (Fig.  6).  It  is  situate 
about  an  inch  in  front  of  the  lambda,  and  occurs  in 
over  4  per  cent,  of  newly  born  children  (Lea).  The 
parietal  foramina  are  remains  of  this  interval. 

Wormian  bones. — These  irregular  bones 
may  be  mistaken  for  fragments  produced  by  frac- 
ture. They  are  most  usually  met  with  in  the  lamb- 
doid  suture.  One  Wormian  bone  deserves  special 
notice,  as  it  may  be  met  with  in  trephining  over 
the  middle  meningeal  artery.  It  exists  between  the 
anterior  inferior  angle  of  the  parietal  bone  and 
the  great  wing  of  the  sphenoid.  It  is  scale-like, 
and  gives  the  impression  that  the  tip  of  the  great 
wing  has  been  separated.  It  is  known  as  the 
cpipteric  bone. 

Necrosis  is  fairly  common  on  the  vault  of 
the  skull,  and  most  often  attacks  the  frontal 
and  parietal  bones,  while,  for  reasons  that 
are  not  very  obvious,  it  is  rare  in  the  occi- 
pital bone.  The  external  table  is  frequently 
necrosed  alone,   it  being  more  exposed  to  injury 


22  SURGICAL   APPLIED    ANATOMY      [Part  I 

and  less  amply  supplied  with  blood  than  is 
the  internal  table.  From  the  converse  of  these 
reasons  it  happens  that  necrosis  of  the  internal 
table  alone  is  but  rarely  met  with.  Necrosis  in- 
volving the  entire  thickness  of  the  bone  may  prove 
very  extensive,  and  in  a  case  reported  by  Saviard, 
practically  the  whole  of  the  cranial  vault  necrosed 
and  came  away.  The  patient  was  a  woman,  and 
the  primary  cause  of  the  mischief  was  a  fall  upon 
the  head  when  drunk. 

Necrosis  of  the  skull,  as  well  as  caries  of  the 
part,  is  attended  by  certain  special  dangers  that 
depend  upon  the  anatomical  relations  of  the 
cranial  bones. 

Thus,  when  the  whole  thickness  of  the  skull  is 
involved  by  disease,  or  when  the  inner  table  is 
especially  attacked,  a  collection  of  pus  may  form 
between  the  dura  mater  and  the  affected  bone,  and 
may  produce  compression  of  the  brain.  When  the 
diploic  tissue  is  implicated,  the  veins  of  that  part 
may  become  thrombosed,  or  may  be  the  seat  of  a 
suppurative  phlebitis.  The  mischief  thus  com- 
menced may  spread,  the  great  intracranial  sinuses 
may  be  closed  by  thrombus,  or  septic  matter  may 
be  conveyed  into  the  general  circulation  and  lead 
to  the  development  of  pyaemia. 

Mere  local  extension  may  also  cause  meningitis. 
In  cases  of  necrosis  of  the  external  table  the  growth 
of  granulation  tissue  from  the  exposed  and  vascu- 
lar diploe  plays  a  very  important  part  in  aiding 
the  exfoliation  of  the  lamella  of  dead  bone. 

Fractures  of  the  skull. — It  is  not  easy  to 
actually  fracture  the  skull  of  a  young  infant.  The 
skull  as  a  whole  at  this  age  is  imperfectly  ossified, 
the  sutures  are  wide,  and  between  the  bones  there 
is  much  cartilage  and  membrane.  Moreover,  the 
bones  themselves  in  early  life  are  elastic,  and  com- 
paratively soft  and  yielding.  If  a  blow  be  inflicted 
upon  the  vault  in  a  young  child  the  most  probable 
effect,  so  far  as  the  bone  itself  is  concerned,  is  an 
indenting  or  bulging  in  of  that  bone  unassociated 
with  a  fracture  in  the  ordinary  sense.    In  this  par- 


Chap.  II]    THE   VAULT   OF   THE   CEANIUM  23 

ticular  relation,  the  skull  of  an  infant  is  to  that  of 
an  old  man  as  a  cranium  of  thin  tin  would  be  to  a 
cranium  of  strong  earthenware.  The  yielding  char- 
acter of  the  young  child's  skull  is  well  illustrated 
by  the  gross  deformity  of  the  head  that  certain 
Indian  tribes  produce  in  their  offspring  by  apply- 
ing tight  bandages  to  the  part  in  infancy.  In  the 
Royal  College  of  Surgeons  museum  are  many 
skulls  of  "flat-headed"  Indians,  that  show  to  what 
an  extreme  this  artificial  deformity  may  be  carried. 
Gueniot  also  asserts  that  much  deformity  of  the 
head  may  be  produced  in  infants  by  the  practice 
of  allowing  them  to  always  lie  upon  one  side  of  the 
body.  Here  the  deforming  agent  is  simply  the 
weight  of  the  brain. 

Even  in  adults  the  skull  is  much  less  brittle 
than  is  commonly  supposed,  and  notions  as  to  the 
breaking  ability  of  the  cranial  bones  derived  from 
the  study  of  the  dried  specimens  are  apt  to  be 
erroneous.  During  life  a  sharp  knife  properly 
directed  may  be  driven  through  the  cranial  vault  so 
as  to  cause  only  a  simple  perforating  wound  with- 
out splintering,  and  without  fracture  of  the  bone 
beyond  the  puncture.  Such  a  wound  may  be  as 
cleanly  cut  as  a  wound  through  thick  leather,  and 
a  specimen  in  the  London  Hospital  museum  serves 
well  to  illustrate  this.  A  case  reported  in  the 
Lancet  for  1881  affords  a  strange  instance  of  a  knife 
penetrating  the  skull  without  apparently  splinter- 
ing the  bone.  A  man  wishing  to  commit  suicide 
placed  the  point  of  a  dagger  against  the  skull  in 
the  upper  frontal  region,  and  then  drove  it  well 
into  the  brain  by  a  blow  from  a  mallet.  He  ex- 
pected to  fall  dead,  and  was  disappointed  to  find 
that  no  phenomena  of  interest  developed.  He  then 
drove  the  dagger  farther  in  by  some  dozen  blows 
with  the  mallet,  until  the  blade,  which  was  four 
inches  long,  was  brought  to  a  standstill.  The 
dagger  was  removed  with  great  difficulty,  the 
patient  never  lost  consciousness,  and  recovered 
without  a  symptom. 

The    following    anatomical    conditions    tend  to 


24  SUBGtfCAL   APPLIED    ANATOMY       [Part  I 

minimise  the  effects  of  violence  as  applied  to  the 
skull  :  the  density  of  the  scalp  and  its  great 
mobility  ;  the  dome-like  arrangement  of  the  vault ; 
the  number  of  the  bones  that  compose  the  head, 
and  the  tendency  of  the  violence  to  be  broken  up 
amongst  the  many  segments  ;  the  sutures  which 
interrupt  the  continuity  of  any  given  force,  and  the 
sutural  membrane,  which  acts  as  a  kind  of  linear 
buffer ;  the  mobility  of  the  head  upon  the  spine ; 
and  the  elasticity  of  the  cranial  bones  themselves. 

The  skull  is  further  strengthened  by  the  pre- 
sence of  six  buttresses  or  pillars  at  the  junction  of 
the  vault  and  base.  Two  of  these  are  lateral,  the 
orbito-sphenoid  anteriorly  and  the  petro-mastoid 
posteriorly,  while  the  fronto-nasal  and  occipital 
strengthen  the  anterior  and  posterior  ends  of  the 
skull. 

In  children  the  membranous  layer  between  the 
sutures  is  of  considerable  thickness,  but  as  age 
advances  this  membrane  disappears  and  the  bones 
tend  to  fuse  together  (synostosis).  The  sutures 
begin  to  be  obliterated  about  the  age  of  forty,  the 
change  commencing  on  the  inner  aspect  of  the 
suture,  and  appearing  first  in  the  sagittal  suture, 
then  in  the  coronal  and  lambdoid,  and  last  in 
the  squamous.  As  age  advances,  moreover,  the 
skull  bones  become  thicker  owing  to  a  deposit  over 
the  inner  table  to  replace  the  diminishing  brain, 
and  lose  much  of  their  elasticity.  They  are,  there- 
fore, more  readily  fractured  in  the  aged  than  in 
the  young. 

As  a  rule,  in  fracture,  the  entire  thickness  of  the 
bone  is  involved  ;  but  the  external  table  alone  may 
be  broken,  and  may  even  be  alone  depressed,  being 
driven  into  the  cliploe,  or,  in  the  case  of  the  lower 
frontal  region,  into  the  frontal  sinus.  The  internal 
table  may  be  broken  without  a  corresponding  frac- 
ture in  the  outer  plate ;  and  in  nearly  all  cases 
of  complete  fracture,  especially  in  such  as  are  at- 
tended with  depression,  the  internal  table  shows 
more  extensive  splintering  than  does  the  external. 
There   are  many   reasons  for  this.     The   internal 


Chap.  II]    THE   VAULT   OF   THE  CRANIUM 


25 


plate  is  not  only  thinner  than  the  external,  but  is 
so  much  more  brittle  as  to  receive  the  name  of  the 
"vitreous  table.  A  force  applied  to  the  external 
table  may  be  extremely  limited,  and  produce,  as  in 
a  sabre  cut,  but  a  limited  lesion.  As  the  force, 
however,    travels    through    the    diploe    it   becomes 


broken  up,  and  reaches  the  inner  plate  as  a  much 
more  diffused  form  of  violence.  This  is  especially 
the  case  when  parts  of  the  outer  table  are  driven 
in.  Then,  again,  the  internal  plate  is  a  part  of  a 
smaller  curve  than  is  the  external  plate  ;  and, 
lastly,  Agnew  assigns  a  reason  for  the  greater  vul- 


nerability of  the  inner  plate  that  has  reference 
to  the  general  yielding  of  the  bone.  In  Fig.  7* a  b 
represents  a  section  of  a  part  of  the  vault  through 
both  tables,  and  c  d  and  e  f  two  vertical  and  paral- 
lel lines.  Now,  if  force  be  applied  to  the  vault  be- 
tween these  parallel  lines,   the  ends  of  the  arch, 


26  SUPGtfCAL   APPLIED    ANATOMY      [Part  1 

A  b,  will  tend  to  become  separated,  and  the  whole 
arch,  yielding,  will  tend  to  assume  the  curve  shown 
in  Fig  8.  In  such  case,  the  lines  c  d  and  e  f  will 
converge  above  and  diverge  below  (Fig.  8),  so  that 
the  violence  would  tend  to  force  the  bone  particles 
together  at  the  outer  table  and  asunder  at  the 
inner  table. 

Fractures    of  the    vault    are    due    to    direct 
violence.     The  construction  of  the   skull  is   such 
that  the  fracturing  force  is  resisted  in  many  ways. 
(1)  When  a  blow  is  received  on  the  vertex  in  the 
parietal  region,  the  force  tends  to  drive  the  upper 
borders  of  the  two  parietal  bones  inwards.     Such 
driving-in  of  these  borders  must  be  associated  with 
a  corresponding  outward  movement  of  the  inferior 
borders.     This  latter  movement  is  forcibly  resisted 
by  the  squamous  bone  and  the  great  wing  of  the 
sphenoid,   which   overlap   the  lower  edge   of  the 
parietal  bone.     Moreover,  the  force  transmitted  to 
the  squamous  bone  is  passed  on  to  the  zygomatic 
arch,   which  takes  its  support  from  the   superior 
maxillary  and  frontal  bones.    This  arch  then  acts  as 
a  second  resisting  buttress,  and  this  transmission 
of  force  from  the  vertex  to  the  facial  bones  is  said 
to  be  illustrated  by  the  pain  often  felt  in  the  face 
after  blows  upon  the  top  of  the  head.     (2)  If  the 
upper  part  of  the  frontal  bone  be  struck,  the  force 
is  at  once  transmitted  to  the  parietal  bones,  be- 
cause the  upper  part  of  the  frontal  bone  (owing  to 
the  manner  in  which  its  border  is  bevelled)  actu- 
ally rests  upon  the  two  parietal  bones,  so  the  same 
resistance  is  again  called  into  action.  If  there  be  any 
tendency  for  the  inferior  parts  of  the  bone  to  move 
outwards,  as  would  certainly  be  the  case  while  the 
mid-frontal  suture  existed,   such  movement  would 
be  resisted  by  the  great  wings  of  the  sphenoid  and 
by  the  anterior  inferior  angles  of  the  parietal  bones 
which    embrace    or    overlap    these    parts    of    the 
frontal.     Thus  it  will  be  seen  that  much  depends 
upon  the  manner  in  which  the  corresponding  edges 
of  the  frontal  and  parietal  bones  are  bevelled.     (3) 
Blows   upon   the   occiput   are   less   distinctly   pro- 


Chap.  II]    THE  VAULT   OF   THE  CRANIUM  27 

vided  for,  and  it  must  be  owned  that  a  by  no 
means  heavy  fall  is  sufficient  to  break  this  bone. 
It  must  receive,  however,  much  protection  from 
its  connections  with  the  two  parietal  and  tem- 
poral bones,  and  from  its  articulation  with  the 
elastic   vertebral   column. 

Fractures  of  the  base  of  the  skull  may 
be  due  to  (1)  direct  or  to  ^)  indirect  violence,  or, 
most  commonly  of  all,  to  (3)  extension  of  a  fracture 
from  the  vault.  (1)  The  base  has  been  fractured 
Iry  direct  violence  due  to  foreign  bodies  thrust 
through  the  nasal  roof,  through  the  orbital  roof, 
and  through  the  base  as  it  presents  in  the  pharynx. 
The  posterior  fossa  can  also  be  fractured  by  vio- 
lence applied  to  the  nape  of  the  neck.  (2)  Of  frac- 
tures by  indirect  violence  the  following  examples 
may  be  given  :  Blows  applied  to  the  lower  part  of 
the  frontal  bone  have  been  associated  with  no 
lesion  other  than  a  fracture  of  the  cribriform 
plate  or  of  the  orbital  part  of  the  frontal, 
these  parts  being  much  disposed  to  fracture 
on  account  of  their  extreme  tenuity.  In  86 
cases  of  fracture  of  the  base  of  the  skull,  the 
orbital  roof  was  involved  in  79,  the  optic  foramina 
in  63,  and  the  cribriform  plates  in  nearly  all  (Rawl- 
ing).  In  falls  upon  the  chin,  the  condyle  of  the 
lower  jaw  has  been  so  violently  driven  against  the 
glenoid  cavity  as  to  fracture  the  middle  fossa  of  the 
skull.  The  force  of  a  "knock-out",  blow  applied 
to  the  point  of  the  chin  produces  concussion  of  the 
brain  without  fracture  of  the  skull.  When  the  body 
in  falling  has  alighted  upon  the  feet,  knees,  or  but- 
tocks, the  force  has  been  transmitted  along  the 
vertebral  column,  and  has  led  to  fracture  of  the 
base  in  the  occipital  region.  Such  accidents  are 
most  apt  to  occur  when  the  spine  is  kept  rigid  by 
muscular  action,  and  the  mechanism  involved  is 
precisely  similar  to  that  whereby  the  head  of  a 
broom  is  driven  more  firmly  on  to  the  broom-handle 
by  striking  the  extreme  end  of  the  stick  against 
the  ground.  The  theory  that  the  base  is  often 
broken  by  contre-coup  is  pretty  generally  abandoned, 


28  SUEGICAL   APPLIED    ANATOMY       [Part  I 

although  there  are  a  few  cases  that  appear  to  sup- 
port the  suggestion.  Such  a  case  was  recorded  by 
Mr.  Hutchinson,  and  in  it  a  fracture  of  the  occipital 
bone  was  associated  with  a  like  lesion  in  the  cribri- 
form plate,  the  intervening  part  of  the  skull  being 
uninjured.  (3)  Fractures  of  the  vault,  and  especi- 
ally linear  fractures  due  to  such  diffused  violence 
as  obtains  in  a  fall  upo%the  head,  are  very  apt  to 
spread  to  the  base.  In  so  spreading  they  reach  the 
base  by  the  shortest  possible  route,  and  without 
any  regard  to  the  sutures  encountered  or  to  the 
density  of  the  bones  involved.  Thus,  fractures  of 
the  frontal  region  of  the  vault  spread  to  the  an- 
terior fossa  of  the  base,  those  of  the  parietal  region 
to  the  middle  fossa,  and  those  of  the  occipital 
region  to  the  posterior  fossa.  To  this  rule  there  are 
but  few  exceptions.  To  indicate  more  precisely  the 
exact  bones  involved  in  these  three  districts,  P. 
Hewett  has  divided  the  skull  into  three  zones.  The 
anterior  zone  includes  the  frontal,  the  upper  part 
of  the  ethmoid,  and  the  f  ronto-sphenoid ;  the 
middle,  the  parietals,  the  squamous  and  anterior 
part  of  the  petrous  of  the  temporals,  and  the 
greater  part  of  the  basi-sphenoid ;  and  the  pos- 
terior, the  occipital,  the  mastoid,  the  posterior 
part  of  the  petrous  bone,  with  a  small  part  of 
the  body  of  the  sphenoid. 

In  all  fractures  of  the  base  there  is  usually  a 
discharge  of  blood  and  of  cerebro-spinal  fluid  ex- 
ternally. (1)  In  fractures  of  the  anterior  fossa  the 
blood  usually  escapes  from  the  nose,  and  is  derived 
from  the  meningeal  and  ethmoidal  vessels,  or  in 
greater  degree  probably  from  the  torn  mucous  lin- 
ing of  the  nasal  roof.  To  allow  of  the  escape  of 
cerebro-spinal  fluid  from  the  nose,  there  must  be, 
in  addition  to  the  fracture  in  the  nasal  roof,  a  lacer- 
ation of  the  mucous  membrane  below  that  fracture, 
and  of  the  sheaths  of  the  olfactory  nerves  which  are 
derived  from  the  dura  mater  and  arachnoid.  A 
profuse  discharge  of  cerebro-spinal  fluid  may  take 
place  through  the  nasal  mucous  membrane  inde- 
pendently of  injury.     The   discharge   probably  oc- 


Chap.  II]    THE   VAULT   OF   THE   CEANIUM  29 

curs  along  the  sheaths  of  the  olfactory  nerves,  and 
is  caused  by  a  lessened  absorption  or  increased 
secretion  of  cerebro-spinal  fluid.  In  many  cases 
of  fracture  in  this  part  the  blood  finds  its  way  into 
the  orbit,  and  appears  beneath  the  conjunctiva.  (2) 
When  the  middle  fossa  is  involved,  the  blood 
escapes  from  the  external  auditory  meatus,  through 
a  rupture  in  the  tympanic  membrane,  and  is  de- 
rived from  the  vessels  of  the  tympanum  and  its 
membrane,  or  from  an  intracranial  extravasation, 
and  in  some  cases  from  a  rupture  of  the  cavernous 
or  petrosal  sinuses.  The  blood  may  follow  the 
Eustachian  tube,  and  may  escape  from  the  nose  or 
mouth,  or  be  swallowed  and  subsequently  vomited. 
To  allow  of  the  escape  of  cerebro-spinal  fluid  by  the 
ear  ("the  serous  discharge  "),  (a)  the  fracture  must 
have  passed  across  the  internal  auditory  meatus; 
(b)  the  tubular  prolongation  of  the  membranes  in 
that  meatus  must  have  been  torn ;  (c)  there  must 
be  a  communication  between  the  internal  ear  and 
the  tympanum  ;  and  (d)  the  membrana  tympani 
must  have  been  lacerated.  (3)  In  fractures  of  the 
posterior  fossa  an  extravasation  of  blood  may  ap- 
pear about  the  mastoid  process  or  at  the  nape  of 
the  neck,  or  may  even  extend  into  the  cervical  region. 

It  may  be  added  that  in  compound  fractures 
of  the  vault  associated  with  tearing  of  the  dura 
mater  and  arachnoid,  an  escape  of  cerebro-spinal 
fluid  has  in  a  few  rare  instances  been  noted.  After 
simple  fracture  of  the  vault  in  children  a  swelling 
may  form  at  the  injured  part  which  fluctuates,  be- 
comes tenser  when  the  patient  cries,  and  may  pos- 
sibly pulsate  synchronously  with  the  brain.  Such 
swellings  are  clue  to  a  collection  of  cerebro-spinal 
fluid  beneath  the  scalp,  and  indicate  a  coincident 
rupture  of  the  brain  membranes. 

Separation  of  sutures. — This  condition,  as 
the  result  of  injury,  is  practically  restricted  to  the 
young  skull.  In  later  life,  force  applied  at  the  site 
of  an  obliterated  suture  may  cause  a  fracture, 
which  accurately  follows  the  old  suture  line.  Separ- 
ation of  the  sutures,  independent  of  fracture,   is 


30  SUEGICAL    APPLIED    ANATOMY       [Part  I 

very  rare  in  the  adult  skull.  In  the  few  instances 
of  such  a  condition  the  temporal  bone  has  usually 
been  the  one  displaced  and  the  separation  noted 
at  the  squamous  suture.  When  associated  with 
fracture,  the  coronal  and  sagittal  sutures  are  those 
most  frequently  separated,  and  next  in  fre- 
quency is  the  lambdoid. 

The  thickness  of  the  skull  cap  varies 
greatly,  not  only  in  different  parts  of  the  same 
skull,  but  also  in  corresponding  parts  in  different 
individuals.  The  average  thickness  is  one-fifth  of  an 
inch.  It  varies  with  age  ;  at  birth  the  parietal  is 
less  than  TV  inch ;  at  three  years  diploe  appear, 
marking  off  the  inner  from  the  outer  table  of  the 
skr:  11;  in  old  people  the  parietal  bone  may  be 
\  inch  or  \  inch  in  thickness.  The  thickest 
parts  are  at  the  occipital  protuberance  (where  the 
section  may  measure  half  an  inch),  the.  mastoid 
process,  and  the  lower  part  of  the  frontal  bone. 
The  bone  over  the  inferior  occipital  fossae  and  orbit 
is  very  thin,  while  it  is  thinnest  over  the  squamous 
bone.  Here. the  bone  may  be  no  thicker  in  parts 
than  a  visiting  card.  The  skull  is  also  thinned 
over  the  sinuses  and  grooves  for  the  meningeal 
vessels.  It  is  especially  thin  over  the  anterior  in- 
ferior angle  of  the  parietal  bone.  It  is  important 
to  remember  in  trephining  that  the  inner  table  is 
not  always  parallel  with  the  outer. 

Craniectomy.  —  This  operation  is  carried  out 
in  cases  of  microcephaly  in  infants  and  chil- 
dren. It  consists  in  the  removal  of  a  strip  of  bone 
from  the  vertex  of  the  skull  so  as  to  give  to  the 
brain,  as  an  American  author  expresses  it,  "  more 
elbow  room."  The  operation  presumes  that  the 
arrest  of  growth  in  the  brain  is  due  to  a  retarded 
growth  of  the  skull,  but  all  the  evidence  at  our  dis- 
posal points  to  the  arrest  in  the  development  of 
the  brain  as  the  primary  lesion  ;  the  condition  of 
the  skull  being  a  consequence.  In  hydrocephaly 
the  skull  is  seen  to  respond  readily  to  the  quick 
expansion  of  the  brain  ;  if  the  growth  of  the  brain 
is  arrested,  the  skull  remains  small. 


CHAPTER  III 
THE    CRANIAL    CONTENTS 

Membranes  of  tlie  brain. — The  dura  mater, 
from  its  toughness,  forms  an  excellent  protec- 
tion to  the  brain.  It  is  very  intimately  adherent 
to  the  bone  over  the  whole  of  the  base  of  the 
skull,  and  consequently  in  this  situation  extrava- 
sations between*  the  membrane  and  the  bone  are 
scarcely  possible.  Over  the  vault  its  attachments 
are  comparatively  loose,  although  it  is  more  closely 
adherent  along  the  lines  of  the  sutures.  This  lax 
attachment  allows  large  hsemorrhagic  and  puru- 
lent extravasations  to  collect  between  the  dura 
mater  and  the  bone.  Such  extravasations  usually 
lead  to  compression  of  the  brain,  and  it  may  be 
noted  that  in  the  great  majority  of  all  cases  of 
compression  the  compressing  force  is  outside  the 
dura  mater.  Thus,  in  uncomplicated  cases  when 
symptoms  of  compression  come  on  at  the  time  of 
an  accident,  the  cause  is  probably  depressed  bone ; 
when  they  appear  after  a  short  interval,  the  cause 
is  probably  extravasated  blood  between  the  mem- 
brane and  the  bone;  and  when  a  long  interval 
(days  or  weeks)  has  elapsed  after  the  accident,  the 
cause  is  probably  a  collection  of  pus  in  the  same 
situation. 

Sir  C.  Bell  pointed  out  that  the  dura  mater  of 
the  vault  may  be  separated  from  the  bone  by  the 
vibration  produced  by  a  blow.  "Strike  the  skull 
of  a  subject  with  a  heavy  mallet ;  on  dissecting  you 
find  the  dura  mater  to  be  shaken  from  the  skull  at 

31 


32  SUEGICAL    APPLIED    ANATOMY       [Part  I 

the  point  struck.  Repeat  the  experiment  on  an- 
other subject,  and  inject  the  head  minutely  with 
size  injection,  and  you  will  find  a  clot  of  injection 
lying  betwixt  the  skull  and  dura  mater  at  the  part 
struck,  and  having  an  exact  resemblance  to  the 
coagulum  found  after  violent  blows  on  the  head." 
Tillaux  has  demonstrated  that  the  adhesions  be- 
tween the  dura  mater  and  the  bone  are  particularly 
weak  in  the  temporal  fossae,  the  most  usual  site  of 
meningeal  haemorrhage. 

When  blood  is  poured  out  between  the  dura 
mater  and  the  bone  in  cases  of  fracture,  the  vessel 
that  as  a  rule  gives  way  is  the  middle  menin- 
geal artery.  In  thirty-one  cases  of  such 
haemorrhage,  this  vessel  was  the  source  of  the 
bleeding  in  twenty-seven  instances  (P.  Hewett). 
The  vessel,  having  passed  through  the  foramen 
spinosum,  divides  into  two  branches  ;  the  anterior, 
the  larger,  runs  upwards  across  the  anterior  in- 
ferior angle  of  the  parietal  bone  and  ascends  the 
vault  some  distance  behind  the  coronal  suture  ; 
the  posterior  runs  backwards,  with  a  horizontal 
sweep  across  the  squamous  bone,  and  takes  the 
course  of  the  second  temporal  convolution.  (See 
Figs.  2,  3.) 

Mr.  Jacobson  has  shown  that  the  branches  of  the 
artery  are  more  frequently  ruptured  than  the 
trunk.  The  vessel  is  very  frequently  torn  as  it 
crosses  the  anterior  angle  of  the  parietal  bone. 
There  are  many  reasons  for  this  :  the  bone  where 
grooved  by  the  artery  is  very  thin  ;  the  artery  is 
often  so  embedded  in  the  bone  that  fracture  with- 
out laceration  of  the  vessel  would  hardly  be  pos- 
sible ;  and  lastly,  the  particular  region  of  the 
artery  is  a  part  of  the  skull  peculiarly  liable  to  be 
fractured.  Mr.  Jacobson  shows  that  the  artery  may 
be  ruptured  by  a  force  that  does  not  fracture  the 
skull,  but  merely  leads  to  detachment  of  the  dura 
mater.  Failing  this  vessel,  the  most  frequent 
source  of  extrameningeal  haemorrhage  is  the 
lateral  sinus,  for  reasons  that  will  be  obvious. 
Venous  sinuses.  — The  flaccid-walled  cerebral 


Chap.  Ill]      THE    CRANIAL    CONTENTS  33 

veins,  which  are  compressed  with  each  pulsa- 
tion of  the  brain,  empty  into  the  venous  sinuses, 
rigid-walled  cavities  formed  between  the  outer  or 
periosteal  and  inner  or  supporting  layers  of  the 
dura  mater.  At  the  points  where  the  superior 
cerebral  veins  enter  the  superior  longitudinal 
sinus,  and  wThere  the  temporo-sphenoidal  and 
occipital  veins  join  the  lateral  sinus,  the  arach- 
noid, elsewhere  free  from  dura  mater,  is  firmly 
adherent  to  it.  From  a  surgical  point  of  view 
the  lateral  is  the  more  important  sinus;  and  as 
it  turns  downwards  beneath  the  mastoid  process 
it  comes  into  close  relationship  with  the  antrum 
and  cells  of  the  mastoid,  from  which  a  septic  con- 
dition may  spread  to  the  sinus,  setting  up  throm- 
bosis (see  Fig.  20,  p.  86).  The  lateral  sinus  is 
marked  out  by  taking  the  following  three  points 
(see  Fig.  2,  p.  9,  and  Fig.  3,  p.  12)  :  (1)  The 
inion,  (2)  the  asterion,  (3)  a  point  h  inch  behind 
the  lower  border  of  the  meatus.  When  these 
three  points  are  joined,  the  upper  and  anterior 
borders  of  the  sinus  are  marked  out.  The  sinus 
is  10  mm.  wide.  The:  lateral  sinus  escapes  from 
the  skull  to  form  the  internal  jugular  vein  in  line 
with  the  anterior  border  of  the  mastoid  process, 
but  situated  deeply  beneath  the  parotid  gland 
(Fig.  2,  p.  9).  A  line  drawn  over  the  vault  of  the 
skull  from  nasion  to  inion  marks  the  line  of  the 
superior  longitudinal  sinus;  beneath  the  posterior 
third  of  the  sagittal  suture  it  may  not  keep  exactly 
to  the  middle  line,  and  in  this  part  of  its  course 
it  frequently  shows  lateral  extensions  or  diverti- 
cula known  as  parasinoids.  In  the  majority  of 
cases  the  superior  longitudinal  ends  in  the  right 
lateral  sinus,  which  is  hence  commonly  larger 
than  the  left.  <  The  cavernous  sinus,  enclosing  the 
internal  carotid  artery  and  sixth  cranial  nerve, 
with  the  third,  fourth  and  greater  part  of  the  fifth 
embedded  in  its  wall,  is  situated  over  the 
sphenoidal  air  sinus^  from  which  septic  conditions 
may  extend  to  it,  giving  rise  to  thrombosis.  In 
such  cases  the  eyes  become  prominent  owing  to  the 

D 


34  SUEGICAL   APPLIED    ANATOMY       [Part  I 

distension  of  the  ophthalmic  veins,  for  the  venous 
stream  from  the  orbit  flows  through  the  cavernous 
sinus  to  reach  the  lateral  sinus  and  jugular  vein  by 
means  of  the  superior  and  inferior  petrosal  sinuses. 
Tumours  of  the  pituitary  necessarily  compress  the 
cavernous  sinus.  The  relations  between  the  inter- 
nal carotid  artery  and  cavernous  sinus  are  so  in- 
timate that  an  arterio-venous  aneurism  has  fol- 
lowed injury  involving  these  parts.  It  will  be 
seen  also  with  what  ease  this  sinus  could  become 
thrombosed  in  cases  of  inflammation  within  the 
orbit  by  the  extension  of  the  mischief  along  its 
great  tributaries,  the  two  ophthalmic  veins. 

Between  the  dura  mater  and  the  arachnoid  is 
the  subdural  space,  which,  like  the  pleural 
cavity,  is  merely  a  potential  space,  for  in  health 
the  arachnoid  is  closely  applied  to  the  smooth 
inner  surface  of  the  dura  mater^  A  space  is  formed 
only  when  fluid,  blood,  or  pus  is  collected  between 
the  two  membranes  (Fig.  1,  p.  2).  The  subdural 
space  contains  a  small  amount  of  fluid,  and  acts, 
probably,  like  the  pleural  and  peritoneal  sacs,  in 
preventing  the  effects  of  friction  during  the  move- 
ments of  the  brain. 

A  knowledge  of  the  subarachnoid  space  is 
steadily  becoming  of  greater  surgical  importance. 
The  space  which  surrounds  the  spinal  cord  is  in 
direct  continuity  with  the  subarachnoid  spaces  of 
the  brain,  and  hence,  when  this  space  is  tapped 
in  the  lumbar  part  of  the  spinal  canal  (Fig.  107, 
p.  612),  the  fluid  situated  in  the  subarachnoid 
spaces  of  the  brain  is  also  drained  off  (Fig.  9).  In 
meningitis  the  cerebro-spinal  fluid  becomes  turgid  ; 
the  subarachnoid  space,  or  parts  of  it,  may  contain 
pus.  In  the  spinal  column  the  arachnoid  is  widely 
separated  from  the  pia  mater,  hence  the  subarach- 
noid space  is  extensive.  As  the  space  passes  into 
the  skull  it  forms  an  expansion  between  the  cere- 
bellum and  roof  of  the  fourth  ventricle  named  the 
cisterna  magna  (Fig.  9);  an  opening  in  the  roof 
of  the  fourth  ventricle  (the  foramen  of  Majendie) 
allows  the  cerebro-spinal  fluid  in  the  ventricles  of 


Chap.  III1      THE    CRANIAL    CONTENTS 


35 


the  brain  to  join  that  in  the  cisterna  magna  (Fig. 
9).  On  the  base  of  the  skull,  in  front  of  the  medulla 
and  pons,  the  spinal  subarachnoid  space  expands 
into  the  cisterna  pontis,  which  in  turn  becomes 
continuous  with  a  large  space  situated  on  the  base 
of  the  brain  between  the  temporal  lobes  and  under 
the  inter-peduncular  space — the  cisterna  basalis 
(Fig.  9).  In  this  cistern  are  situated  the  circle  of 
Willis,    the   third,    fourth,    and   root  of   the   fifth 


Calloso  /1arcinal  Space 

Supra  Cauosal  Space 

Splenium 
Velum  Interpositun 

Pl/IEAL   C.LAND 

Tentorium  Cerebelli 

Aqueduct  ofSylvius 
Four.™  Ventricle 
Foramen  of/IajendiEt 
Cisterna  macna 


Cut  edge  of  Arachnoid 

Supra- CallosalSpace 

Lateral  Ventricie; 

Genu 

Foramen  of 
aionro 
Third 
entricle 

Sub  Callosal 
Space 

Cisterna 
Basalis 

Optic 
/terve 
Pituitary 
Body 
_  Internal 
arotid  art- 
Temporal  L0B& 


iro  /Ierve 


Cisterna  Spinalis 


Cisterna    Pontis 
^Cisterna  /Iedullaris 
.Cisterna  Spinalis 


Fig.  9. — Diagram  of  the  cranial  spaces  containing  cerebro-spinal  fluid. 


nerves,  the  optic  chiasma  and  tracts  and  infundi- 
bulum  of  the  pituitary  body.  In  basal  meningitis 
it  may  become  distended  with  pus.  The  inflam- 
matory adhesions  which  occur  in  the  inferior 
medullary  velum  may  lead  to  a  condition  of 
hydrocephaly  by  closing  up  the  openings  in  that 
membrane.  Over  the  convolutions  of  the  brain 
the  arachnoid  is  bound  by  the  pia  mater,  which 
here  serves  as  a  loose  subarachnoid  tissue.  Every- 
where extensions  of  the  basilar  cistern  pass  out 
with  the  arteries  derived  from  the  circle  of  Willis 
into  the  pia  mater  in  the  sulci  of  the  brain.    While 


36  SURGICAL   APPLIED    ANATOMY       [Part  I 

the  interpeduncular  part  of  the  base  of  the  brain, 
pons  and  medulla  rest  on  these  basal  cisterns,  the 
temporal  and  frontal  lobes  lie  directly  on  the  base 
of  the  skull ;  the  occipital  lobe  rests  on  the  tentor- 
ium cerebelli.  >  The  three  poles  of  the  brain— the 
frontal,  occipital  and  temporal — are  in  direct 
contact  with  the  meninges  and  skull,  and  are 
therefore  the  parts  of  the  brain  that  are  most 
liable  to  laceration  in  cases  of  injury  to  the  head. 

The  cerebro-spinal  fluid  prevents  the  ill  effects 
that  irregularities  in  the  blood  circulation  might 
have  upon  the  brain,  situate  as  it  is  within  an  un- 
yielding cavity.  If  the  great  nerve  centres  near  the 
lateral  ventricles  are  swollen  by  congestion,  they 
are  not  met  by  an  unyielding  wall,  but  merely  dis- 
place some  of  the  cerebro-spmal  fluid  through  the 
foramen  of  Majendie,  until  such  time  as  their  cir- 
culation is  normal  again.  When  the  healthy  brain 
is  exposed  by  a  trephine  opening  it  is  seen  to 
pulsate  with  each  beat  of  the  heart;  if  it  does 
not  pulsate,  this  shows  that  the  pressure  within 
the  skull  is  higher  than  the  arterial  pressure 
(100-130  mm.  Hg.);  normally,  as  Hill  has  shown, 
the  intracranial  pressure  is  that  of  the  blood- 
pressure  in  the  veins  (10-15  mm.  Hg.).  With  each 
pulsation  of  the  heart  about  5  cm.  of  arterial  blood 
is  thrown  into  the  skull,  causing  the  ejection  of  a 
similar  amount  of  venous  blood  by  the  jugular 
vein. 

Fluid  may  pass  from  the  lateral  to  the  third 
ventricle  by  the  foramen  of  Monro ;  from  the  third 
to  the  fourth  ventricle  by  the  aqueduct  of  Sylvius  ; 
and  from  the  fourth  ventricle  to  the  cisterna 
magna  by  the  foramen  of  Majendie  (Fig.  9).  Many 
still  share  the  opinion  of  Hilton  that  blockage  of 
the  aqueduct,  or  closure  of  the  foramen  of 
Majendie,  or  of  the  other  two  openings  at  the 
lateral  angles  of  the  fourth  ventricle — (the  fora- 
mina of  Key  and  Retzius) — may  prevent  the  exit  of 
cerebro-spinal  fluid  from  the  ventricles  and  thus 
produce  the  condition  of  hydrocephaly.  The  fluid 
also  drains  into  the  veins  of  Galen,  hence  pressure 


Chap.  Ill]      THE    CRANIAL    CONTENTS  37 

on  these  may  bring  about  a  like  result.  It  has  been 
proposed  to  relieve  the  pressure  within  the  lateral 
ventricles  in  cases  of  hydrocephaly  by  draining  the 
cerebro-spinal  fluid  into  the  subdural  space  by 
means  of  a  seton.  It  is  absorbed  under  any  pressure 
above  that  within  the  cerebral  veins  (Hill).  If  the 
brain,  too,  becomes  enlarged  by  congestion,  it  is 
not  met  by  unyielding  bone,  but  rather  by  an  ad- 
justable water-bed,  and  during  its  period  of  en- 
largement it  merely  displaces  into  the  spinal  part 
of  the  subarachnoid  space  some  of  the  fluid  that 
surrounds  it.  This  mutual  effect  is  well  illustrated 
in  a  case  reported  by  Hilton  of  a  man  with  a  frac- 
ture of  the  base,  from  whose  ear  cerebro-spinal 
fluid  was  escaping.  The  discharge  of  this  fluid 
was  at  once  greatly  increased  by  expiratory  efforts 
when  the  nose  and  mouth  were  held  closed  and  the 
veins  compressed  in  the  neck. 

The  surface  relationships  of  the  Drain 
(see  Figs.  10  and  11). — The  longitudinal  fissure  of  the 
brain  is  indicated  by  a  line  drawn  along  the  vertex 
from  the  glabella  to  the  external  occipital  protu- 
berance. It  is  narrow  in  front,  but  as  it  contains 
the  longitudinal  sinus,  which  rapidly  enlarges  as 
it  passes  backwards,  it  becomes  of  considerable 
breadth  behind,  and  as  a  rule  lies  somewhat  to- 
wards the  right  of  the  median  line,  owing  to  the 
predominance  of  the  left  cerebral  hemisphere. 
Between  the  external  occipital  protuberance  and 
the  ear,  the  lateral  sinus  bounds  the  lower  level  of 
the  cerebrum  and  the  upper  of  the  cerebellum 
(Figs.  3  and  10).  In  front  of  the  ear  the  upper 
border  of  the  zygoma  in  its  posterior  three-fourths 
marks  the  lower  border  of  the  temporal  lobe.  The 
pole  of  the  temporal  lobe  is  f  of  an  inch  behind  the 
outer  margin  of  the  orbit  (see  Fig.  3).  The  lower 
limit  of  the  brain  on  the  forehead  may  be  indicated 
approximately  by  drawing  a  line  from  the  glabella 
to  the  Sylvian  point,  ^  an  inch  above  the  upper 
margin  of  the  orbit.  The  olfactory  bulbs  lie  at 
the  level  of  the  nasio_n  (Fig.  3). 

The  cerebellum  is  best  explored  at  a  point  1^ 


38 


SUKGICAL   APPLIED    ANATOMY      [Part  I 


inch  behind  and  |  inch  below  the  level  of  the 
external  auditory  meatus  (see  Fig.  3,  p.  12).  _  It 
is  deeply  placed,  being  covered  by  the  insertions 
of  the  occipital  muscles. 


FISSURE  of  ROLANDO. 


PARIETAL 
EMINENCE 


BREQMA 


r-NASION 


Fig.  10. — Showing  the  relation  of  the  brain  and  sensori-motor  areas  of 
the  cortex  to  the  skull.    {Modified  from  Quain.) 

The  sensori-motor  areas  are  shaded ;  the  leg  and  trunk  areas  with  vert  Lea]  lines  ; 
the  arm  and  hand  areas  with  lines  slanting  forwards;  the  face  and  mouth 
areas  with  lines  slanting  backwards;  the  tongue,  pharynx,  and  larynx  areas 
are  stippled.  The  ascending  frontal  convolution,  containing  the  areas  which 
are  strictly  motor  in  function,  is  indicated  by  red  lines.  The  motor  centre  for 
speech  on  Broca's  convolution  is  shaded  with  horizontal  lines.  The  "word- 
hearing"  centre  is  indicated  on  the  superior  temporal  convolution,  and 
the'  "word-seeing"  centre  on  the  angular  convolution.  The  area  shaded 
with  horizontal  lines  on  the  posterior  parts  of  the  middle  and  inferior  frontal 
convolutions  is  the  centre  for  combined  movements  of  I  he  head  and  eyes. 

Of   the   many   methods   which   have   been   sug- 
gested for  marking  out  the  fissure  of"  Rolando, 

the  most  simple  and  accurate  is  the  following  :  A 
point  over   the  sagittal   suture   is  taken   midway 


Chap.  Ill]       THE    CRANIAL    CONTENTS 


39 


between  the  glabella  and  external  occipital  pro- 
tuberance. Half  an  inch  behind  the  mid  point 
terminates  the  upper  end  of  the  fissure  (Fig. 
11).     A  line  3h  inches  long  drawn  downwards  and 


Upper 
rolandic 

POINT 

MID  POINT. 

PARIETO- 
OCCIPITAL 
FISSURE 

PAf^EMIN. 

LAMBDA./S 

X 

BRECMA. 


WON. 


Fig.  11. — Showing  the  lines  which  indicate  the  position  of  the  principal 
fissures  of  the  brain. 

Reid's  base  line  is  drawn  from  the  lower  margin  of  the  orbit  backwards  through 
the  meatal  point. 


forwards  from  this  point,  at  an  angle  of  67°  to 
the  line  of  the  sagittal  suture,  will  indicate  the 
position  of  the  fissure  of  Rolando  in  the  adult. 
In  the  child  the  fissure  is  shorter  and  the  con- 
tained angle  is  5°  smaller.     The   angle   is  easily 


40  SURGICAL   APPLIED    ANATOMY       [Part  I 

obtained  by  folding  twice  the  corner  of  a  square 
piece  of  paper  and  removing  a  fourth  of  the 
right  angle.  This  line  may  not  lie  exactly  oyer 
the  fissure,  for  it  varies  somewhat  in  position 
according  to  the  shape  of  head.  The  sensori- 
motor areas  of  the  brain  are  mostly  represented 
in  the  ascending  frontal  and  parietal  convolu- 
tions which  bound  the  fissure  of  Rolando.  The 
average  width  of  each  of  these  convolutions  is 
J  of  an  inch.  The  coronal  suture  is  about  2  inches 
in  front  of  the  fissure  of  Rolando  at  its  upper 
part  and  1|  inch  at  its  lower. 

The  fissure  of  Sylvius  is  indicated  thus 
(Fig.  11)  : — A  point  is  taken  1|  inch  behind 
and  \  inch  above  the  fronto-malar  junction, 
which  is  indicated  by  a  distinct  notch.  This  point 
on  the  temple  overlies  the  anterior  inferior  angle 
of  the  parietal  bone — the  pterion.  The  pterion 
marks  the  junction  of  the  three  limbs  of  the 
fissure  of  Sylvius  with  its  stem.  A  line  drawn 
backwards  and  upwards  from  the  pterion  to  a 
point  |  of  an  inch  below  the  parietal  eminence 
indicates  the  situation  of  the  posterior  horizontal 
limb  or  ramus  (Fig.  11).  If  the  parietal  eminence 
be  not  well  marked,  then  the  fissure  may  be  in- 
dicated by  joining  the  fronto-malar  notch  with 
the  pterion  and  prolonging  the  line  thus  formed 
straight  backwards  to  the  region  of  the  parietal 
eminence,  as  shown  in  Fig.  3  (R.  J.  Berry).  This 
ramus  is  bounded  below  by  the  superior  temporal 
convolution,  which  contains  in  its  middle  third 
the  "word-hearing"  centre  (Fig.  10).  Above,  it 
is  bounded  from  before  backwards  by  the  basilar 
part  of  the  inferior  frontal  convolution,  the  lower 
ends  of  the  ascending  frontal  and  parietal  con- 
volutions, and  the  supramarginal  gyrus.  In  the 
three  parts  first  named  are  situated  centres  for 
movements  of  the  tongue,  larynx,  pharynx  and 
mouth.  A  penny  piece  placed  directly  behind  the 
termination  of  the  Sylvian  line  will  cover  the 
angular  convolution  in  which  the  "word-seeing  ;; 
centre  is  placed  (Fig.  10).     The  parietal  eminence 


Chap.  Ill]       THE    CRANIAL    CONTENTS  4,1 

covers  the  supramarginal  convolution.  The  ascend- 
ing limb  of  the  fissure  of  Sylvius  is  indicated 
by  a  line  f  of  an  inch  long  drawn  upwards  and 
slightly  forwards  from  the  pterion,  while  the  short 
anterior  horizontal  limb  is  indicated  by  a  line 
\  an  inch  long  drawn  forwards  from  the  same 
point.  Between  the  ascending  and  anterior  limbs 
is  situated  the  pars  triangularis  of  the  inferior 
frontal  convolution  in  which  the  centre  for 
"  motor  speech  ,;  is  placed.  Broca  regarded  the 
left  inferior  frontal  convolution  (frequently 
called  Broca's  convolution)  as  specially  connected 
with  speech,  but  recently  Pierre  Marie  has  pub- 
lished accounts  of  a  number  of  cases  of  disease  of 
this  part  in  which  speech  was  unaffected.  The 
stem  of  the  Sylvian  fissure  is  \  an  inch  long  and 
runs  downwards  and  forwards  under  the  great 
wing  of  the  sphenoid  (Fig.  10).  The  temporal 
pole  lies  below  it. 

The  four  angles  of  the  parietal  bone  have  im- 
portant relationships  to  the  brain.  The  anterior 
inferior  angle  covers  the  posterior  part  of  the  in- 
ferior frontal  convolution  and  the  anterior  hori- 
zontal and  ascending  limbs  of  the  fissure  of  Syl- 
vius. The  anterior  branch  of  the  middle  meningeal 
artery  ascends  beneath  it.  The  anterior  superior 
angle  at  the  bregma  covers  the  terminal  part  of 
the  superior  frontal  convolution  and  the  centre 
for  movements  of  the  hip.  The  posterior  superior 
angle  at  the  lambda  lies  oyer  the  upper  part  of  the 
occipital  lobe  and  \  an  inch  behind  the  parieto- 
occipital fissure.  The  posterior  inferior  angle 
covers  the  convexity^  of  the  lateral  sinus  and 
marks  the  lower  limit  of  the  cerebrum.  In  its 
anterior  half  the  posterior  limb  of  the  Sylvian 
fissure  lies  beneath  the  squamous  suture,  but  be- 
hind it  passes  entirely  beneath  the  parietal  bone. 
It  will  be  thus  seen  that  the  parietal  bone  covers 
the  whole  of  the  parietal  lobe,  the  posterior  parts 
of  the  frontal  and  temporo-sphenoidal  lobes,  and 
the  upper  margin  of  the  occipital. 

The    inferior  temporal  convolution  passes 


42  SURGICAL    APPLIED    ANATOMY       [Part  I 

backwards  above  the  upper  border  of  the  zygoma 
and  external  auditory  meatus  and  rests  on  the 
thin  roof  of  the  tympanum.  Hence  it  is  the_  most 
common  site  of  abscess  which  may  follow  middle- 
ear  disease.     (Fig.   10.) 

The  basal  ganglia  of  the  brain — the  corpus 
striatum  and  optic  thalamus — are  capped  on  their 
outer  aspect  by  the  Island  of  Eeil.  The  Island 
lies  buried  in  the  anterior  three-fourths  of  the 
fissure  of  Sylvius,  and  hence  the  surface  markings 
for  the  fissure  may  be  also  used  for  the  Island 
and  the  basal  ganglia  (see  Fig.  3,  p.  12).  A 
half-circle,  with  a  radius  of  ■§•  an  inch,  drawn 
in  front  of  the  pterion,  will  indicate  the  anterior 
limit  of  the  basal  ganglia,  while  their  posterior 
limit  lies  some  distance  in  front  of  the  point  at 
which  the  lateral  ventricles  may  be  tapped  (see 
Fig.  3,  p.  12).  That  point  is  found  thus  :  a 
line  5  cm.  (2  inches)  in  length  is  drawn  verti- 
cally upwards  from  the  external  auditory  meatus ; 
the  point  for  tapping  the  lateral  ventricle  lies 
2  cm.  ( f  of  an  inch)  behind  the  upper  end  of 
this  line ;  a  trochar  thrust  in  there  enters  the 
lateral  ventricle  at  the  junction  of  the  body  with 
the  descending  and  posterior  horns.      (Jenkins.) 

The  sensori-motor  areas  of  the  brain. — A 
knowledge  of  the  position  of  these  areas  is  most 
important  in  enabling  certain  brain  lesions  to  be 
localised  and  in  guiding  the  surgeon  in  operations 
upon  the  cerebral  cortex. 

Formerly  these  areas  were  believed  to  be  situ- 
ated in  the  ascending  frontal  (precentral)  and  also 
ascending  parietal  (postcentral)  convolution,  but 
by  stimulating  more  accurately  the  cortex  of  these 
convolutions  in  anthropoid  apes,  Sherrington  and 
Griinbaum  found  that  motor  reactions  were 
elicited  only  from  the  ascending  frontal.  The 
arrangement  of  the  motor  areas  is  shown  in  Fig. 
12  :  in  the  upper  third  of  the  ascending  frontal, 
passing  also  some  distance  on  to  the  mesial  aspect 
of  the  brain,  the  movements  of  the  lower  extremity 
and  trunk  are  represented;  in  the  middle  third, 


Chap.  IIIJ      THE    CRANIAL    CONTENTS 


43 


those  of  the  arm ;  while  in  the  lower  third,  those 
of  the  face,  mouth,  and  larynx.  Behind  the  fis- 
sure of  Rolando,  in  the  ascending  parietal  con- 
volution, are  situated  sensory  areas  corresponding 
to  the  motor  areas  in  the  ascending  frontal  con- 
volution. A  tumour  pressing  on  the  surface  of 
the  brain  first  excites  the  cortex  to  action ;  hence 
one  situated  over  a  motor  area  excites  the  move- 


Pirsf  IzrnpoY^/^ 


Fig.  12.— Showing  the  localisation  of  motor  areas  in  the  precentral  or 

ascending  frontal  convolution,  and  the   sensory  areas  in  the  postcentral 

or  ascending  parietal  convolution. 


ments  represented  in  that  area,  or  one  over  a  sen- 
sory area  excites  the  sensations  represented  there. 
Stimulation  of  the  cortex  is  soon  followed  by  its 
destruction  and  loss  of  function ;  hence  loss  of 
movement  or  loss  of  sensation  replaces  the  pre- 
liminary excitement.  The  symptoms  produced  by 
intracranial  growths  are  apt  not  to  be  definitely 
localised,  because  even  a  small  tumour  may  pro- 
duce widely  distributed  compression  effects  when 
it  is  situated  within  the  rigid  walls  of  the  skull. 


44  SUEGICAL   APPLIED    ANATOMY.      [Part  I 

Conjugate  movements  of  the  eyes  are  represented 
in  the  cortex  at  the  posterior  end  of  the  mid- 
frontal  convolution  (Fig.  12).  There  are  also 
several  primary  sensory  areas  of  cortex — areas 
connected  with  sight,  hearing,  and  smell — which 
may  be  affected  by  intracranial  lesions,  and  give 
signs  which  assist  the  surgeon  to  localise  the  seat 
of  disease.  The  visual  cortex  is  situated  near  the 
calcarine  fissure  and  round  the  occipital  pole; 
the  "  word-seeing "  centre  occupies  the  angular 
gyrus  (Fig.  10) ;  the  auditory  cortex  lies  in  a  deep 
or  buried  part  of  the  superior  temporal  convolu- 
tion, while  the  "word-hearing"  centre  is  ascribed 
to  the  middle  third  of  this  convolution.  The  ol- 
factory cortex  is  placed  in  the  uncus,  which  is 
situated  to  the  inner  side  of  the  temporal  lobe. 
Tumours  in  the  neighbourhood  of  the  uncus, 
besides  producing  disturbance  of  the  olfactory 
sensations,  frequently  give  rise  to  "  dreamy 
states." 

Of  the  brain  generally  little  has  to  be  said. 
In  a  surgical  sense,  it  presents  itself  simply  as 
a  large  mass  of  soft  tissue  that  may  be  damaged 
by  shaking  as  gelatine  may  be  shaken  in  a  case. 
As  it  is  of  very  yielding  structure,  and  does  not 
entirely  fill  the  cranial  cavity,  it  may,"  as  it  were, 
be  thrown  about  with  the  skull,  and  be  damaged 
by  collision  with  its  walls.  In  contusion  or  bruis- 
ing of  the  brain  it  is  noticed  that  the  lesion  is 
very  much  more  frequently  situate  on  the  under 
surface,  both  as  regards  the  cerebrum  and  cere- 
bellum, than  in  any  other  part  (see  p.  36).  To 
this  statement,  however,  there  is  the  striking 
exception  that  those  parts  of  the  base  of  the 
cerebrum  that  rest  upon  the  large  basal  collection 
of  the  cerebro-spinal  fluid  are  the  least  often  con- 
tused. These  parts  include  the  medulla,  the  pons, 
and  the  interpeduncular  space. 

The  brain  is  very  lavishly  supplied  with  blood- 
vessels. The  main  arterial  trunks  (vertebral  and 
internal  carotid)  are  both  rendered  tortuous  be- 
fore entering  the  skull,  with  the  object  probably  of 


Chap.  Ill]       THE    CRANIAL    CONTENTS  45 

diminishing  the  effects  of  the  heart's  systole  upon 
the  brain.  On  entering  they  are  almost  immedi- 
ately blended  into  an  anastomosing  circle  (circle 
of  Willis),  which  has  the  effect  of  equalising  the 
cerebral  circulation.  Embolism  of  the  middle 
cerebral  artery  leads  to  a  wide-spread  destruc- 
tion of  the  cerebral  cortex.  It  supplies  the  third 
frontal,  the  upper  and  middle  temporal,  the  angu- 
lar supramargpnal,  and  the  lower  two-thirds  of 
the  ascending  frontal  and  parietal  gyri.  The  only 
jd arts  of  the  sensor i-motor  areas  which  escape  de- 
struction in  such  a  case  are  those  for  the  lower 
limbs  and  trunk.  The  anterior  cerebral  artery 
supplies  these  centres,  the  mesial  surface  of  the 
frontal  and  parietal  lobes,  and  the  adjacent  part 
of  the  cortex  on  the  outer  aspect.  The  occipital 
lobe  and  temporo-sphenoidal  convolutions  are 
supplied  by  the  posterior  cerebral  artery.  Liga- 
ture of  one  common  carotid  may  produce  no  effect 
upon  the  brain,  although  the  mortality  afterthis 
operation  is  mainly  due  to  cerebral  complications. 
One  carotid  and  the  two  vertebrals  would  appear 
to  be  able  to  bring  enough  blood  to  the  brain, 
which  blood  will  be  as  evenly  distributed  as 
hitherto  by  the  circle  of  Willis.  Both  common 
carotids  have  been  ligatured,  or  one  carotid  has 
been  secured  when  its  fellow  of  the  opposite  side 
has  been  occluded  by  disease,  and  no  marked  cere- 
bral disturbances  have  followed.  In  no  case,  how- 
ever, has  the  patient  recovered  when  the  interval 
between  the  closing  of  the  two  vessels  was  less 
than  a  few  weeks.  The  vertebral  arteries  can 
carry  a  sufficient  amount  of  blood  to  the  brain 
if  only  the  strain  be  thrown  upon  them  gradu- 
ally, and  the  brain  be  allowed  to  accommodate 
itself  slowly  to  the  change.  After  ligaturing  all 
four  arteries  in  the  dog,  the  anastomosis  between 
the  spinal  and  cerebral  arteries  within  the  fora- 
men magnum  was  sufficient  to  maintain  life 
(Hill).  Plugging  of  any  of  the  smaller  cerebral 
arteries  by  emboli,  as  a  rule,  leads  at^  once  to  a 
marked  disastrous  result.     Such  embolism  is  met 


46  SURGICAL    APPLIED    ANATOMY       [Parti 

with  in  surgery  in  connection  with  aneurism  of 
the  common  carotid.  In  simply  examining  such 
aneurisms,  a  little  piece  of  the  clot  contained  in 
the  sac  has  been  detached,  has  been  carried  up 
into  the  brain,  and  has  produced  a  plugging  of 
one  of  the  cerebral  vessels.  Thus,  hemiplegia  has 
followed  upon  the  mere  examination  of  a  carotid 
aneurism,  as  in  a  case  recorded  by  Mr.  Teale,  of 
Leeds.  Fergusson;s  treatment  of  aneurism  at  the 
root  of  the  neck,  by  displacing  the  clots  by  manip- 
ulation, has  been  abandoned  on  this  same  score. 
In  the  second  case  treated  by  manipulation  by 
this  surgeon,  a  case  of  subclavian  aneurism, 
paralysis  of  the  left  side  of  the  body  followed  at 
once  upon  the  first  handling  of  the  tumour. 

The  pulsations  of  the  brain  may  be  communi- 
cated to  any  tumours  or  collections  of  fluid  that 
reach  the  surface  of  the  brain  through  an  aper- 
ture in  the  skull.  Such  pulsations  are  synchron- 
ous with  the  arterial  pulse,  but  the  sphygmo- 
graphic  tracings  of  the  cerebral  pulsations  exhibit 
also  the  "  respiratory  curve/'  conveyed  directly 
from  the  thorax  by  the  blood  within  the  veins. 
The  valve  at  the  lower  end  of  the  jugular  vein 
prevents  direct  regurgitation  of  blood  from  the 
heart  to  the  brain,  but  it  does  not  prevent  the 
transmission  of  pressure. 

Although  wounds  of  the  brain  bleed  freely, 
the  bleeding  is  checked  without  difficulty,  the 
vessels  being  capable  of  ready  contraction.  Large 
tumours  have  been  excised  from  the  cortex  of 
the  brain,  without  undue  trouble  from  haemor- 
rhage. The  terminal  branches  of  the  cerebral 
arteries  anastomose  freely  in  the  pia  mater,  but 
the  minute  arteries  which  perforate  and  supply 
the  cortex  are  terminal.  Hence  any  pressure  ap- 
plied to  the  surface  of  the  brain  will  lead  to 
anaemia  of  that  piece  of.  cortex,  and,  if  the  pres- 
sure is  continued,  to  its  destruction. 

Ligature  of  a  cerebral  vein  usually  leads  to  an 
atrophy  of  the  cortex  which  it  drains  (Horsley). 
There  is  always  one — sometimes  more — anastomos- 


Chap.  Ill]      THE    CliANIAL    CONTENTS  47 

ing  vein  on  the  surface  of  the  cerebrum,  uniting 
the  upper  with  the  lower  cerebral  veins.  The 
lower  cerebral  veins  are  four  in  number — three  of 
them  leave  the  temporal  and  occipital  lobes  to  end 
in  the  lateral  sinus;  the  other,  the  superficial 
Sylvian  vein,  ends  in  the  sinus  of  the  jsmall  wing 
of  the  sphenoid.  The  temporal  and  occipital  lobes 
cannot  be  lifted  off  the  tentorium  without  rup- 
turing the  veins  joining  the  lateral  sinus. 

Nearly  all  the  veins  of  the  cerebellum  end  in 
the  lateral  sinus;  its  arteries  are  derived  from 
vertebral  and  basilar.  Tumours  in  the  cerebel- 
lum give  rise  to  muscular  weakness  and  inco- 
ordination, giddiness,  and  loss  of  balance.  The 
vermis,  or  middle  part  of  the  cerebellum,  is  more 
directly  connected  with  bending  movements  of  the 
trunk,  while  the  lateral  lobes  are  concerned  in 
the  co-ordination  of  turning  movements — move- 
ments made  round  the  vertical  axis  of  the  trunk 
(Horsley). 


CHAPTER  IV 

THE  ORBIT  AND  EYE 

The     orJbit. — The    antero-posterior    diameter    of 
the   orbit    is   about   If   inches   (44  mm.),    its    ver- 
tical diameter  at  the  base  a  little  over  l\  inches 
(31    mm.),    and    its    horizontal    diameter    at    the 
base   about   lj  inches    (37   mm.).      The   diameters 
of  the  globe  are  as  follow  :   transverse,   24  mm. ; 
antero  -  posterior,    24"5    mm. ;    vertical,    23    mm. 
(Brailey).      The    eyeball    is    therefore    nearer    to 
the   upper  and  lower  margins  of  the  orbit  than 
it  is  to  the  sides,   and  the  greatest  interval  be- 
tween  the  globe   and  the  orbital   wall   is  on  the 
outer  side.     The  interior  of  the  orbit  is  most  con- 
veniently reached  by  incisions  made  to  the  outer 
side  of  the  globe,  and,  in  excision  of  the  eyeball, 
the  scissors  are  usually  introduced  on  that  side 
when  the  optic  nerve  has  to  be  divided.     In  excis- 
ing the  left  eye,   however,   it  may  be  more  con- 
venient to  divide  the  optic  nerve  from  the  inner 
side.     The  bones  forming  the  floor,  the  roof,  and 
the  inner  wall  of  the  orbital  cavity  are  very  thin, 
especially    in    the    last-named    situation.     Thus, 
foreign  bodies  thrust  into  the  orbit  have  readily 
penetrated  into  the  cranial  cavity,  into  the  nose 
and    ethmoidal    cells,    and,    when    directed    from 
above,   into  the  antrum.     In  several  instances,   a 
sharp-pointed   instrument,   such  as  the  end  of  a 
stick    or    foil,    has    been    thrust    into    the    brain 
through  the  orbit,  and  has  left  but  little  external 
evidence  of  this  serious  lesion.     Nelaton  mentions 

48 


Chap.  IV]  THE    ORBIT  AND  EYE  49 

a  case  in  which  the  internal  carotid  artery  was 
wounded  through  the  orbit.  Certain  cases  of 
pulsating  orbital  tumour  which  depend  upon  a 
communication  between  the  carotid  artery  and 
the  cavernous  sinus  have  a  traumatic  origin. 

A  reference  to  the  relations  of  the  orbital  walls 
will  show  that  a  tumour  may  readily  invade  the 
orbit  by  spreading  (1)  from  the  base  of  the  skull, 
(2)  from  the  nasal  fossse,  (3)  from  the  antrum, 
and  (4)  from  the  temporal  or  zygomatic  fossse.. 
In  any  of  these  instances  the  growth  may  enter 
the  orbit  by  destroying  the  intervening  thin  layers 
of  bone,  and  in  tumours  of  the  antrum  this  is 
the  usual  mode  of  entry.  It  may,  however,  ex- 
tend more  readily  from  the  cranial  cavity  through 
the  optic  foramen  or  sphenoidal  fissure,  from  the 
nose  through  the  nasal  duct,  and  from  the  two 
fossse  named  through  the  spheno-maxillary  fis- 
sure. After  violent  blows  upon  the  temple  blood 
has  found  its  way  into  the  orbit  through  the 
spheno-maxillary  fissure,  \  and  has  led  to  subcon- 
junctival ecchymosis.  Distension  of  the  frontal 
sinus  by  retained  mucus  or  pus  may  lead  to  a 
prominent  tumour  at  the  upper  and  inner  margin 
of  the  orbit,  above  the  level  of  the  tendo  oculi, 
which  may  cause  displacement  of  the  globe  down- 
wards, outwards,  and  forwards.  The  bones  of  the 
orbit  are  peculiarly  apt  to  be  the  seat  of  ivory 
exostoses,  which  may  in  time  entirely  occupy  the 
orbital  cavity. 

The  anterior  third  .of  the  outer  wall  of  the 
orbit  is  formed  by  the  temporal  fossa  (Fig.  13) ; 
the  posterior  two-thirds  are  separated  from  the 
middle  fossa  of  the  skull,  which  contains  the  tem- 
poral lobe,  by  the  great  wing  of  the  sphenoid. 
Kronlein  removes  intraorbital  tumours  by  open- 
ing the  outer  wall  of  the  orbit  in  the  temporal 
fossa.  In  a  recent  notorious  case,  in  which  a  mur- 
derer attempted  to  commit  suicide,  the  bullet 
entered  the  temporal  fossa,  perforated  the  outer 
wall  of  the  orbit,  and  destroyed  the  eyeball,  but 
left  the  brain  untouched.  The  pole  of  the  tem- 
E 


50 


SUEGICAL   APPLIED    ANATOMY       [Part  I 


poral  lobe  is  situated  from  2  to  2*5  cm.   behind 
the  outer  margin  of  the  orbit  (see  Fig.  3,  p.  12). 

The  capsule  of  Tenon. — The  best  description 
of  this  capsule  has  been  given  by  Mr.  Lockwood ; 
of  his  researches  Prof.  Cunningham  provides  the 
following  resume:  — 


Ext. Tarsal  Lie 
Conjunctiva 
Ext.Chcck, 
Ext-£ec 


Int. Tarsal  Lie 
Lach.  Sac 
Int.  Check.  Liq. 


Capsule  of-Tbnon 
Temporal  Fossa 


Ext.  Rectus 


JLCapsule-opTenon 
Int.  Rectus 
Optic  aierve 

5  ME  ATM 


Middle  fossa 


Fig.  13.     Diagram  to  show  the  arrangement  of  the  capsule  of  Tenon  and 
check  ligaments. 

The  eyeball  is  turned  outwards  so  that  the  external  check  ligament  is  taut  and 
the  internal  relaxed. 

"  The  capsule  is  a  firm  loose  membrane  spread 
over  the  posterior  fths  of  the  globe,  the  cornea 
alone  being  free  from  it.  In  front  it  lies  under 
the  ocular  conjunctiva,  with  which  it  is  intim- 
ately connected,  and  it  ends  by  blending  with 
that  membrane  close  to  the  margin  of  the  cornea 
(Fig.  13).  Behind  it  fuses  with  the  sheath  of  the 
optic  nerve,  where  the  latter  pierces  the  sclerotic. 
The  surface  of  the  membrane  towards  the  globe 
is  smooth,  and  is  connected  to  the  eyeball  by  some 


Chap.  IV]  THE    ORBIT  AND  EYE  51 

soft  yielding  areolar  tissue.  It  thus  forms  a  kind 
of  dome  for  the  globe,  a  species  of  socket  or  bursa 
in  which  it  moves.  The  posterior  surface  of  the 
capsule  is  in  contact  with  the  orbital  fat.  The 
tendons  of  the  ocular  muscles  pierce  the  capsule 
opposite  the  equator  of  the  globe  (Fig.  13).  The 
lips  of  the  openings  through  which  the  four  recti 
pass  are  prolonged  backwards  upon  the  muscles, 
in  the  form  of  sheaths,  very  much  as  the  infundi- 
buliform  fascia  is  prolonged  upon  the  cord  from 
the  internal  abdominal  ring."  Where  the  internal 
and  external  recti  perforate,  strong  expansions 
of  the  capsule  spread  out  to  the  inner  and  outer 
wall  of  the  orbit.  Because  these  expansions  limit 
the  action  of  the  two  recti  they  are  known  as  the 
check  ligaments  (Fig.  13).  They  allow  a  side-to- 
side  movement  of  the  cornea  to  the  extent  of 
about  45°.  The  external  check  ligament  is  the 
stronger,  and  is  attached  to  the  outer  wall  im- 
mediately behind  the  external  tarsal  ligament; 
the  attachment  of  the  internal  ligament  is  close 
behind  the  lachrymal  sac.  A  prolongation  of  the 
capsule  passes  to  the  trochlea  round  the  tendon 
of  the  superior  oblique.  The  suspensory  ligament 
of  the  eyeball  stretches  across  the  orbit  like  a 
hammock,  _  supporting  the  eyeball.  It  is  really 
a  thickening  of  the  under  part  of  the  capsule 
of  Tenon,  its  attachment  to  the  orbital  walls  being 
made  by  means  of  the  internal  and  external  check 
ligaments.  When  the  upper  jaw  is  removed  the 
surgeon  should  take  care  to  preserve  the  attach- 
ments of  the  suspensory  ligament.  If  these  be 
destroyed  the  eyeball  will  sink  downwards. 

The  intimate  relations  of  the  capsule  of  Tenon 
to  the  eyeball,  conjunctiva,  orbital  muscles,  and 
orbital  walls  has  to  be  kept  in  mind  where  opera- 
tions are  undertaken  to  remedy  squint.  From 
Fig.  13,  it  will  be  seen  that  after  the  tendon  of 
a  rectus  muscle  is  cut  through  as  it  lies  within  the 
capsule  of  Tenon,  the  muscle  still  possesses, 
through  the  continuity  of  its  sheath  with  the  cap- 
sule,  an   attachment  to  the  eyeball  and  conjunc- 


52  SURGICAL    APPLIED    ANATOMY       [Part  I 

tiva  as  well  as  to  the  orbital  wall  by  the  check 
ligament.  Hence  when  the  tendon  of  a  muscle  is 
completely  cut  it  can  still  act  on  the  eyeball ;  its 
complete  retraction  is  prevented  by  the  check 
ligament. 

The  orbit  behind  Tenon's  capsule  is  occupied 
by  a  large  quantity  of  loose  fat,  in  addition  to 
the  ocular  muscles,  vessels,  and  nerves.  It  is  by 
the  absorption  of  this  fat  that  the  sunken  eye 
is  produced  in  cases  of  emaciation  and  prolonged 
illness.  This  tissue  affords  a  ready  means  for  the 
spread  of  orbital  abscess.  Such  an  abscess  may 
follow  injuries,  certain  ocular  inflammations, 
periostitis,  etc.,  or  may  spread  from  adjacent 
parts.  The  pus  may  occupy  the  entire  cavity,  dis- 
placing the  eyeball  forwards,  limiting  its  move- 
ments, and  causing,  by  interference  with  the  cir- 
culation, great  redness  of  the  conjunctiva  and 
swelling  of  the  lids. 

Foreign  bodies,  some  of  them  of  remarkable 
size  and  shape,  have  lodged  for  long  periods  of 
time  in  the  orbital  fat  without  causing  much 
trouble.  Thus  Lawson  reports  a  case  where  a 
piece  of  an  iron  hat-peg,  three  inches  long,  was 
embedded  in  the  orbit  for  several  days  without  the 
patient  being  aware  of  it.  A  stranger  case,  in 
some  ways,  is  that  reported  by  Furneaux  Jordan  : 
"  A  man  who  was  employed  in  threshing  became 
the  subject  of  severe  ophthalmia.  At  the  expira- 
tion of  several  weeks,  the  patient,  whilst  pressing 
his  finger  on  the  lower  eyelid,  suddenly  ejected 
from  a  comfortable  bed  of  warm  pus  a  grain  of 
wheat,  which  had  shot  forth  a  vigorous  green 
sprout."  The  orbital  fat  affords  also  an  excellent 
nidus  for  growing  tumours.  Fractures  of  the 
inner  wall  of  the  orbit  involving  the  nasal  fossae 
or  sinuses  may  lead  to  extensive  emphysema  of 
the  orbital  cellular  tissue.  The  air  so  introduced 
may  cause  the  globe  to  protrude,  may  limit  its 
movements,  may  spread  to  the  lids,  and  will,  in 
any  case,  be  increased  in  amount  by  blowing  the 
nose,  etc. 


Chap.  IV]  THE    ORBIT  AND  EYE  53 

The  orbital  muscles. — The  four  recti  muscles 
end  in  thin,  flat  membranous  tendons.  The  ten- 
don of  the  external  or  internal  rectus  muscle  is 
frequently  divided  for  strabismus.  The  width  of 
the  tendons  varies  from  7  mm.  to  9  mm.  They 
are  inserted  into  the  sclerotic  near  the  cornea. 
The  internal  rectus  is  inserted  6'5  mm.  from  the 
corneal  margin,  the  external  6*8  mm.,  the  inferior 
7*2  mm.,  and  the  superior  8  mm.   (Merkel). 

While  the  internal  and  external  recti  are  pure 
internal  and  external  rotators  of  the  eyeball,  the 
superior  and  inferior  recti,  owing  to  the  line  in 
which  they  pull,  act  as  internal  as  well  as  up- 
ward and  downward  rotators.  Their  tendency  to 
act  as  internal  rotators  is  counterbalanced  by  the 
two  oblique  muscles,  which  serve  as  external  as 
well  as  upward  and  downward  rotators. 

The  orbital  arteries  are  small,  and  seldom 
give  rise  to  trouble  when  divided  in  excising 
the  globe,  since  they  can  be  readily  compressed 
against  the  bony  walls  of  the  cavity.  Pulsating 
tumours  of  this  part  may  be  due  to  traumatic 
aneurisms  of  one  of  the  orbital  arteries,  or  may 
depend  upon  an  arterio-venous  aneurism  formed 
between  the  internal  carotid  artery  and  the 
cavernous  sinus.  Pressure  also  upon  the  ophthal- 
mic vein  (as  it  enters  the  sinus),  by  an  aneurism 
of  the  internal  carotid  vessel,  may  produce  all 
the  symptoms  associated  with  pulsating  orbital 
tumours.  Thrombosis  of  the  cavernous  sinus 
causes  dilatation  of  the  ophthalmic  veins  and 
proptosis. 

The  orbital  nerves  may  be  damaged  in 
wounds  of  the  orbit,  or  in  fractures  of  the  orbit 
and  of  the  base  of  the  skull.  They  may  be  pressed 
upon  by  tumours  from  various  parts,  by  aneur- 
isms, hemorrhagic  and  inflammatory  effusions. 
Thus  Lawson  records  a  case  in  which  the  optic 
nerve  was  divided  by  a  stab  through  the  upper 
eyelid,  without  the  globe  being  injured,  and  with- 
out any  bone  being  fractured.  The  same  nerve 
has  also  been  completely  torn  across  in  fractures 


54  SUEGICAL   APPLIED    ANATOMY       [Part  I 

of  the  orbit,  and  has  been  pressed  upon  in  frac- 
tures involving  the  lesser  wing  of  the  sphenoid. 
The  third,  fourth,  and  sixth  nerves,  and  the  first 
division  of  the  fifth,  may  be  affected  in  cases  of 
aneurism  involving  the  internal  carotid  artery, 
where  they  lie  in  relation  with  the  cavernous 
sinus.  They  may  readily  be  pressed  upon,  also, 
by  any  growth  involving  the  sphenoidal  fissure, 
such  as  a  periosteal  node  springing  from  the  mar- 
gin of  the  fissure,  while  the  sixth  nerve,  from  its 
more  intimate  connection  with  the  base  of  the 
skull,  has  been  directly  torn  across  in  a  fracture 
involving  that  part   (Prescott  Hewett). 

In  paralysis  of  the  third  nerve  there  is 
drooping  of  the  upper  lid  (ptosis)';  the  eye_  is 
almost  motionless,  presents  a  divergent  squint 
from  unopposed  action  of  the  external  rectus 
muscle,  and  cannot  be  moved  either  inwards,  up- 
wards, or  directly  downwards.  Rotation,  in  a 
direction  downwards  and  outwards,  can  still  be 
effected  by  the  superior  oblique  and  outer  rectus 
muscles.  The  pupil  is  dilated  and  fixed;  the 
power  of  accommodation  is  much  impaired,  there 
is  diplopia,  and  sometimes  a  little  protrusion  of 
the  globe  from  relaxation  of  the  recti  muscles. 
These  symptoms  refer  tocomplete  paralysis  of  the 
nerve.  In  cases  of  partial  paralysis,  only  one  or 
two  of  the  above  symptoms  may  be  present. 

In  paralysis  of  the  fourth  nerve  there  is 
often  but  little  change  to  be  seen,  since  the  func- 
tion of  the  superior  oblique  muscle,  supplied  by 
this  nerve,  may,  in  part,  be  performed  vicari- 
ously. "  There  is  usually  only  very  slight  defect 
in  the  mobility  of  the  eye ;  what  there  is  occurs 
chiefly  in  the  inner  and  lower  angle  of  the  field 
of  vision ;  there  is  deviation  of  the  eye  inwards 
and  upwards  on  lowering  the  object,  and  simply 
upwards  when  it  is  turned  far  towards  the  healthy 
side  "  (Erb).  In  any  case  there  will  be  diplopia, 
especially  in  certain  positions  of  the  globe. 

In  paralysis  of  the  sixth  nerve  there  is 
convergent  strabismus,  with  consequent  diplopia, 


Chap.  IV  THE    ORBIT  AND  EYE  55 

and  an  inability  to  rotate  the  eye  directly  out- 
wards. Paralysis  of  the  sixth  nerve  may  be  ac- 
companied by  paralysis  of  the  nerve  to  the  in- 
ternal rectus  of  the  opposite  side,  giving  rise  to 
conjugate  deviation  of  the  eyes.  Such  a  condi- 
tion indicates  a  lesion  in  the  nucleus  of  the  sixth 
nerve,  for  although  the  fibres  for  the  internal 
rectus  pass  out  with  the  third  nerve  they  take 
their  origin  with  the  sixth. 

Sometimes  all  the  oculo-motor  nerves  of  the 
eye  are  paralysed,  and  in  such  cases  the  lesion 
is  probably  situated  either  <  at  their  nuclei  of 
origin  or  at  the  cavernous  sinus,  in  the  wall  of 
which  the  nerves  lie  close  together. 

In  paralysis  of  the  first  division  of  the  fifth 
there  is  a  loss  of  sensation  in  all  the  conjunctiva, 
except  such  as  covers  the  lower  lid  (supplied  by 
the  palpebral  branch  of  the  infraorbital  nerve), 
loss  of  sensation  in  the  globe,  and  in  skin  sup- 
plied by  the  supratrochlear  and  supraorbital 
nerves,  and  in  the  mucous  and  cutaneous  surfaces 
supplied  by  the  nasal  nerve.  The  area  of  anaes- 
thesia is  much  less  than  the  anatomical  distri- 
bution of  the  nerve,  owing  to  the  extent  to  which 
cutaneous  nerves  overlap.  No  reflex  movements 
(winking)  follow  upon  irritation  of  the  conjunc- 
tiva, although  the  patient  can  be  made  to  wink 
on  exposing  the  eye  to  a  strong  light,  the  optic 
nerve  in  this  case  transmitting  the  impression  to 
the  facial  nerve.  Sneezing  also  cannot  be  ex- 
cited by  irritating  the  mucous  membrane  in  the 
anterior  part  of  the  nose.  Destructive  ulceration 
of  the  cornea  may  follow  this  paralysis,  due 
partly  to  damage  to  the  trophic  branches  con- 
tained in  the  paralysed  nerve,  partly  _to  the  anaes- 
thesia which  renders  the  part  readily  injured,  and 
partly  to  the  loss  of  the  reflex  effect  of  the  sensory 
nerves  upon  the  calibre  of  the  blood-vessels, 
whereby  the  inflammation  is  permitted  to  go  un- 
controlled  (Nettleship). 

In  paralysis  of  the  cervical  sympathetic 
there  is  narrowing  of  the  palpebral  fissure  from 


56  SUKGICAL   APPLIED    ANATOMY       [Part  I 

some  drooping  of  the  upper  lid,  apparent  reces- 
sion of  the  globe  within  the  orbit,  and  some  nar- 
rowing of  the  pupil  from  paralysis  of  the  dilator 
muscle  of  the  iris,  which  muscle  is  suppliedby  the 
sympathetic.  The  drooping  of  the  upper  lid  may 
be  explained  by  the  fact  that  each  eyelid  contains 
a  layer  of  unstriated  muscle  fibre.  That  in  the 
upper  lid  arises  from  the  under  surface  of  the 
levator  palpebrse,  and  is  attached  to  the  tarsal 
cartilage  near  its  upper  margin  (Fig.  16,  p.  73). 
This  layer  of  muscle,  which,  when  in  action, 
would  keep  up  the  lid,  is  under  the  influence  of 
the  cervical  sympathetic.  The  recession  of  the 
globe  is  supposed  by  some  to  be  due  to  paralysis 
of  the  orbitalis  muscle  of  H.  Miiller.  This  muscle 
bridges  over  the  spheno-maxillary  fissure,  is  com- 
posed of  unstriated  fibres,  and  is  innervated  by  the 
sympathetic.  Contraction  of  the  muscle  (as  pro- 
duced by  stimulation  of  the  cervical  sympathetic 
in  animals)  causes  protrusion  of  the  globe,  while 
section  of  the  sympathetic  in  the  neck  produces 
retraction  of  the  eyeball  (CI.  Bernard).  No 
changes  are  observed  in  the  calibre  of  the  blood- 
vessels of  the  globe.  The  non-striated  muscle 
maintains  the  intraorbital  pressure,  and  thus 
assists  in  the  return  of  blood  from. the  ophthalmic 
veins.  In  animals  such  as  the  ox,  in  which  the 
veins  of  the  orbit  become  dilated  when  the  head 
is  carried  low,  as  in  browsing,  this  musculature 
attains  a  great  development. 

The  globe :  the  cornea. — The  thickness  of  the 
cornea  varies  from  "9  mm.  in  the  central  parts  to 
ri  mm.  at  the  periphery.  One  is  apt  to  be  a 
little  deceived  as  to  its  thickness,  and  on  intro- 
ducing a  knife  into  the  cornea,  the  instrument, 
if  not  entered  at  the  proper  angle,  may  be  thrust 
for  some  little  distance  among  the  laminse  of  the 
part.  In  front  the  cornea  is  covered  by  stratified 
epithelium.  When  this  layer  has  been  removed 
by  abrasion,  a  white  deposit  of  lead  salts  may 
take  place  in  the  exposed  corneal  tissue  in  cases 
whore    lead    lotions    are    used.     The   bulk    of    the 


Chap.  IV] 


THE    ORBIT  AND  EYE 


57 


cornea,  is  made  up  of  a  great  number  of  fibrous 
lamella?,  between  which  are  anastomosing  cell 
spaces  containing  the  corneal  corpuscles.  If  the 
nozzle  of  a  fine  syringe  be  thrust  into  the  corneal 
tissue,  the  network  of  cell  spaces  can  be  filled 
with  injection  (Recklinghausen's  canals).  When 
suppuration  takes  place  within  the  proper 
corneal  tissue,   it  is  probably  along  these  canals, 


Fig.  14. — A  horizontal  section  of  the  globe  through  the  middle. 

a,  Cornea  ;  b,  sclerotic  ;  c,  choroid  ;  <7,  retina  ;  «,  lens  ;  J\  iris  :  <j,  ciliary  process  and 
muscle  ;  //,  canal  of  Sclilrimn. 

modified  by  inflammation,  that  the  pus  spreads, 
thus  producing  onyx.  The  cornea  contains  no 
trace  of  blood-vessels,  except  at  its  extreme  peri- 
phery, where  the  capillaries  of  the  sclerotic  and 
conjunctiva  end  in  loops.  This  lack  of  a  direct 
blood  supply  renders  the  cornea  prone  to  inflame 
spontaneously  in  the  cachectic  and  ill-nourished. 
When  inflamed,  the  tissue  always  becomes  opaque. 
In  the  affection  known  as  interstitial  keratitis, 
blood-vessels  from  the  arteries  at  the  margin  of 
the   cornea    penetrate    into   the    substance    of   the 


58  SUEGICAL   APPLIED    ANATOMY       [Part  I 

cornea  for  some  distance.  As  these  vessels  are 
some  little  way  below  the  surface,  and  are 
covered  by  the  hazy  corneal  tissue  that  is  the  re- 
sult of  the  disease,  their  scarlet  colour  is  much 
toned  down,  and  a  strand  of  such  vessels  is  called 
a  "  salmon  patch."  In  the  condition  known  as 
pannus,  the  cornea  appears  to  be  vascularised ; 
but  here,  owing  to  continued  irritation,  vessels, 
derived  from  the  neighbouring  conjunctival 
arteries,  pass  over  the  cornea  just  beneath  its 
epithelial  covering,  leaving  the  cornea  proper  as 
bloodless  as  ever.  The  term  arcus  senilis  is  ap- 
plied to  two  narrow  white  crescents  that  appear 
at  the  periphery  of  the  cornea,  just  within  its 
margin,  in  the  aged,  and  in  certain  morbid  con- 
ditions. The  crescents  are  placed  at  the  upper 
and  lower  margins,  and  their  points  meet  midway 
on  either  side  of  the  cornea.  They  are  due  to 
fatty  degeneration  of  the  corneal  tissue,  and  the 
change  is  most  marked  in  the  layers  of  the  cornea 
just  beneath  the  anterior  elastic  lamina,  i.e.  in 
the  part  most  influenced  by  the  marginal  blood- 
vessels. In  spite  of  its  lack  of  a  direct  blood 
supply,  wounds  of  the  cornea  heal  kindly.  The 
cornea  is  very  lavishly  supplied  with  nerves,  esti- 
mated to  be  from  forty  to  forty-five  in  number. 
They  are  derived  from  the  ciliary  nerves,  enter 
the  cornea  through  the  fore  part  of  the  sclerotic, 
and  are  distributed  to  every  part  of  the  tunic. 
In  glaucoma,  a  disease  of  which  the  phenomena 
depend  upon  greatly  increased  intraocular  pres- 
sure, the  cornea  becomes  anaesthetic.  This  depends 
upon  the  pressure  to  which  the  ciliary  nerves  are 
exposed  before  their  branches  reach  the  cornea. 
(See  also  Nerve  supply  of  the  eyeball,  p.  63.) 

The  sclerotic,  choroid  and  iris. — The  sclerotic 
is  thickest  behind,  and  thinnest  about  \  of  an 
inch  from  the  cornea.  When  the  globe  is  rup- 
tured by  violence  it  is  the  sclerotic  that  most 
commonly  yields,  the  rent  being  most  usually  a 
little  way  from  the  cornea,  i.e.  in  or  about  the 
thinnest   part  of   the   tunic.       A   rupture   of  the 


Chap.  IV]  THE    OEBIT  AND  EYE  59 

cornea  alone  from  violence  is  not  common.  The 
sclerotic  may  be  ruptured  while  the  lax  conjunc- 
tiva over  it  remains  untorn.  In  such  a  case  the 
lens  may  escape  through  the  rent  in  the  sclerotic, 
and  be  found  under  the  conjunctiva.  At  the  point 
of  penetration  of  the  optic  nerve  the  sclerotic  is 
thin,  and  pierced  by  numerous  holes  for  the  pas- 
sage of  nerve  bundles.  This  weakened  portion, 
the  lamina  cribrosa,  plays  an  important  part  in 
glaucoma  (p.  70).  It  gives  the  stippled  appear- 
ance to  the  optic  papilla.  Brailey  states  that 
the  lateral  parts  of  the  sclerotic  are  thinner  than 
the  upper  and  lower  segments,  the  inferior  part 
being  the  thickest  and  the  external  wall  the  thin- 
nest. It  happens,  therefore,  that  under  the  influ- 
ence of  intraocular  pressure  the  eye  expands  more 
laterally  than  in  the  vertical  direction.  It  is 
mainly  to  the  denseness  and  unyielding  character 
of  the  sclerotic  that  must  be  ascribed  the  severe 
pain  (due  to  pressure  on  nerves)  experienced  in 
those  eye  affections  associated  with  increased  in- 
traocular tension  (glaucoma,  etc.). 

The  choroid  is  the  vascular  tunic  of  the  globe, 
and  carries  its  mam  blood-vessels.  Between  the 
choroid  and  sclerotic  are  two  thin  membranes,  the 
lamina  suprachoroidea  and  lamina  fusca,  which 
are  separated  from  one  another  by  a  lymph 
space.  In  injuries  to  the  globe,  therefore,  ex- 
tensive bleeding  may  take  place  between  these  two 
coats,  and  indeed  a  like  haemorrhage  may  be  the 
result  simply  of  a  sudden  diminution  in  the 
ocular  tension  produced  by  such  an  operation  as 
iridectomy  or  cataract  extraction.  The  choroid 
alone  has  been  ruptured  (usually  at  its  posterior 
part)  as  the  result  of  a  blow  upon  the  front  of 
the  eye.  The  choroid  is  one  of  the  few  parts  of 
the  body  that  may  be  the  seat  of  melanotic 
growths.  These  growths  are  sarcomatous  tumours 
containing  a  large  amount  of  pigment,  and  occur 
only  where  pigment  cells  are  found.  In  the 
choroid  coat  pigment  cells  are  very  abundant. 

The  iris   is,    from   its    great   vascularity,    very 


60  SURGICAL   APPLIED    ANATOMY       [Part  I 

easily  inflamed.  From  its  relations  to  the  cornea 
and  sclerotic  it  happens  that  inflammation  in  those 
tunics  can  spread  without  difficulty  to  the  iris. 
On  the  other  hand,  the  vessels  of  the  iris  and 
choroid  are  so  intimately  related  that  inflamma- 
tions set  up  in  the  iris  itself  have  every  induce- 
ment to  spread  to  the  choroidal  tunic.  When  the 
iris  is  inflamed  its  colour  becomes  altered,  owing 
to  the  congestion  of  the  part  and  to  the  effusion  of 
lymph  and  serum  that  takes  place  in  its  substance. 
The  swelling  to  which  it  becomes  subject,  together 
with  the  effusion,  produce  a  blurring  of  its  delicate 
reticulated  structure,  as  seen  through  the  cornea. 
Owing  also  to  the  swollen  condition  of  the  little 
membrane,  the  pupil  becomes  encroached  on, 
and  appears  to  be  contracted,  while  the  move- 
ments of  the  membrane  are  necessarily  rendered 
very  sluggish.  If  it  be  remembered  that  the  greater 
part  of  the  posterior  surface  of  the  iris  is  in  actual 
contact  with  the  lens  capsule,  it  will  be  understood 
that  inflammatory  adhesions  may  readily  take 
place  between  the  two  parts  (Fig.  14).  After  iritis, 
therefore,  it  is  common  to  find  the  posterior  sur- 
face of  the  iris  (most  often  its  pupillary  margin) 
adherent  to  the  lens  capsule  by  bands  of  lymph, 
either  entirely  or  in  one  or  more  different  points. 
Such  adhesions  constitute  posterior  synechise,  the 
term  anterior  synechise  being  applied  to  adhesions 
between  the  iris  and  the  cornea.  In  iritis  also 
the  lens  may  become  involved,  and  the  con- 
dition of  secondary  or  inflammatory  cataract  be 
produced. 

The  iris  is  not  very  closely  attached  at  its  inser- 
tion. Thus,  in  case  of  injury  to  the  eye,  it  may  be 
torn  more  or  less  from  its  attachments  without  any 
damage  being  done  to  the  other  tunics.  The  iris 
has  been  completely  torn  away  in  a  few  instances, 
and  has  escaped  through  a  wound  of  the  globe. 
The  ciliary  processes  have  been  thus  exposed. 
Congenital  absence  of  the  iris  has  been  recorded. 
In  cases  of  penetrating  wounds  of  the  cornea  the 
iris  is  easily  prolapsed.    It  is  so  delicate  and  yield- 


Chap.  IV]  THE    ORBIT  AND  EYE  61 

ing  a  membrane  that  in  performing  iridectomy  the 
necessary  piece  of  the  iris  can  be  seized  and  pulled 
out  through  the  corneal  incision  without  offering 
sensible  resistance.  The  membrane  also  derives 
much  support  from  its  contact  with  the  lens,  for 
in  cases  where  the  lens  has  been  displaced  into  the 
vitreous,  or  has  been  removed  by  operation,  the 
iris  is  observed  to  be  tremulous  when  the  globe  is 
moved.  Although  very  vascular,  the  iris  seldom 
bleeds  much  when  cut,  a  circumstance  that  is  pro- 
bably due  to  the  contraction  of  the  muscular  fibres 
that  exist  so  plentifully  within  it.  Sometimes  the 
iris  presents  in  its  substance  a  congenital  gap  that 
runs  from  the  pupil  downwards  and  a  little  in- 
wards. This  condition  is  known  as  coloboma  iridis, 
and  is  due  to  the  persistence  of  the  "  choroidal 
cleft."  In  other  cases  there  can  be  seen,  stretch- 
ing across  the  pupil,  some  shreds  of  the  pupillary 
membrane.  Normally  this  membrane,  which  is  ap- 
parent for  a  few  days  after  birth  in  some  animals, 
is  entirely  absorbed  before  birth. 

It  will  now  be  convenient  to  take  note  of  the 
blood  and  nerve  supply  of  the  globe. 

Blood  supply  of"  the  eyeball. —  1.  The 
short  ciliary  arteries  (from  the  ophthalmic)  pierce 
the  sclerotic  close  to  the  optic  nerve,  run  some 
little  way  in  the  outer  coat  of  the  choroid,  and  then 
break  up  into  a  capillary  plexus  that  makes  up  the 
main  part  of  the  inner  choroidal  coat.  In  front  this 
plexus  gives  some  vessels  to  the  ciliary  processes. 
The  veins  from  these  vessels  are  disposed  in  curves 
as  they  converge  to  four  or  five  mam  trunks  (venae 
vorticosse),  which  pierce  the  sclerotic  midway  be- 
tween the  cornea  and  the  optic  nerve.  In  the 
choroid  they  lie  externally  to  the  arteries. 

2.  The  two  long  ciliary  arteries  (from  the 
ophthalmic)  pierce  the  sclerotic  to  the  outer  side 
of  the  optic  nerve  and  run  forwards,  one  on  either 
side,  until  they  reach  the  ciliary  region,  where  they 
break  up  into  branches  that,  by  anastomosing, 
form  a  vascular  circle  about  the  periphery  of  the 
iris  (the  circulus  major).     From  this  circle  some 


62  SUEGMCAL   APPLIED    ANATOMY       [Part  I 

branches  pass  to  the  ciliary  muscle,  while  the  rest 
run  in  the  iris  in  a  converging  manner  towards  the 
pupil,  and  at  the  margin  of  the  pupil  form  a 
second  circle  (the  circulus  minor). 

3.  The  anterior  ciliary  arteries  (from  the  mus- 
cular and  lachrymal  branches  of  the  ophthalmic) 
pierce  the  sclerotic  (perforating  branches)  ^  about 
2-3  mm.  behind  the  cornea,  join  the  m  circulus 
major,  and  give  off  branches  to  the  ciliary  pro- 
cesses, where  they  form  copious  anastomosing 
loops.  These  arteries  lie  in  the  subconjunctival 
tissue.  Their  episcleral  or  non-perforating  branches 
are  very  small  and  numerous,  and  are  invisible 
in  the  normal  state  of  the  eye.  In  inflammation 
of  the  iris  and  adjacent  parts,  however,  these  ves- 
sels appear  as  a  narrow  pink  zone  of  fine  vessels 
round  the  margin  of  *bhe  cornea,  that  run  nearly 
parallel  to  one  another,  are  very  closely  set,  and 
do  not  move  with  the  conjunctiva.  This  zone  is 
known  as  the  zone  of  ciliary  congestion,  or  the  cir- 
cumcorneal  zone. 

4.  The  vessels  of  the  conjunctiva  are  derived 
from  the  lachrymal  and  the  two  palpebral  arteries. 
These  vessels,  in  cases  of  inflammation,  are  readily 
distinguished  from  thoselast  described.  They  are 
of  comparatively  large  size,  are  tortuous,  are  of  a 
bright  brick-red  colour,  can  be  easily  moved  with 
the  conjunctiva,  and  as  easily  emptied  of  their 
blood  by  pressure.  The  differences  presented  by 
thesetwo  sets  of  vessels  serve  in  one  way  to  dis- 
tinguish inflammation  of  the  conjunctiva  from  that 
involving  deeper  parts.  The  conjunctival  vessels 
around  the  margin  of  the  cornea  form  a  closer 
plexus  of  anastomosing  capillary  loops,  which  be- 
come congested  in  severe  superficial  inflammation 
of  the  cornea,  and  may  then  form  a  zone  around 
the  margin  of  the  cornea,  which  can,  however,  be 
distinguished  from  the  "  ciliary  zone  "  by  the 
general  characters  just  named.  The  retina  has  a 
vascular  system^  of  its  own,  supplied  through  the 
arteria  centralis  retinae,  which  is  nowhere  in 
direct  communication  with  the  choroidal  vessels, 


Chap.  IV]  THE    ORBIT  AND  EYE  63 

except  just  at  the  entrance  of  the  optic  nerve. 
Indeed,  the  outer  layers  of  the  retina  which  are  in 
relation  with  the  choroid  coat  are  entirely  destitute 
of  vessels.  Thus,  when  the  central  artery  of  the 
retina  becomes  plugged,  sudden  blindness  follows, 
and  as  the  meagre  collateral  circulation  that  is 
established  by  the  minute  anastomoses  about  the 
entrance  of  the  nerve  is  quite  insufficient,  the  re- 
tina soon  becomes  oedematous.  A  permanent  plug- 
ging of  the  central  artery  means,  therefore,  a  prac- 
tical extinction  of  the  vascular  system  of  the  re- 
tina. In  some  cases  of  embolism  only  a  branch  of 
the  retinal  artery  is  plugged,  the  patient  retaining 
vision  except  in  that  par,t  of  the  retina  supplied 
by  the  branch.  The  fovea  centralis,  the  centre  of 
acute  vision,  receives  twigs  from  both  the  superior 
and  inferior  temporal  branches  of  the  arteria 
centralis  retinae. 

In  cases  of  haemorrhage  between  the  choroid 
and  retina  the  blood  must  come  from  the  choroidal 
vessels ;  and  in  haemorrhage  into  the  vitreous, 
which  often  follows  injury,  the  blood  may  be  de- 
rived from  the  retinal  vessels,  since  they  run  in  the 
inner  layers  of  that  membrane,  or  from  the  vessels 
in  the  ciliary  region. 

Nerve  supply  of  the  eyeball. —  1.  The 
ciliary  nerves  derived  from  the  lenticular  ganglion 
and  the  nasal  nerve  pierce  the  sclerotic  close  to  the 
optic  nerve,  and  pass  forwards  between  the  sclero- 
tic and  the  choroid,  supplying  those  parts.  They 
enter  the  ciliary  muscle,  form  a  plexus  about  the 
periphery  of  the  iris,  and  then  send  fibres  into 
the  iris,  which  form  a  fine  plexus  as  far  as 
the  pupil.  They  send  branches  through  the  fore 
part  of  the  sclerotic  to  the  cornea.  Thus  the  eye- 
ball obtains  through  these  nerves  its  sensory  fibres 
from  the  nasal  branch  of  the  first  division  of  the 
fifth,  its  motor  fibres  for  the  ciliary  muscle  and 
sphincter  iridis  from  the  third  nerve,  and  many 
sympathetic  fibres,  among  which  are  those  that 
supply  the  dilator  muscle  of  the  iris. 

2.     The  conjunctiva  is  supplied  by  four  nerves  : 


64  SURGICAL   APPLIED    ANATOMY       [Part  I 

above,  the  supratrochlear ;  inner  side,  the  inf ra- 
trochlear ;  outer  side,  the  lachrymal  (all  branches 
of  the  first  division  of  the  fifth)  ;  below,  the  palpe- 
bral branches  of  the  second  division  of  the  fifth. 
As  the  ciliary  nerves  pass  forwards  between  the 
choroid  and  the  sclerotic,  it  will  be  seen  that  they 
are  readily  exposed  to  injurious  pressure  against 
the  unyielding  sclerotic  in  cases  of  increased  intra- 
ocular tension. 

The  sensation  of  the  globe  itself  is  derived  solely 
from  the  first  division  of  the  fifth.  In  inflammatory 
affections  of  the  globe,  as  in  corneitis  or  iritis,  be- 
sides the  pain  actually  felt  in  the  eye,  there  is 
pain  referred  along  other  branches  of  the  first  divi- 
sion of  the  fifth.  The  explanation  of  this  fact  has 
to  be  sought  for  in  the  common  origin  of  the 
ophthalmic  division  from  the  upper  sensory 
nucleus  of  the  fifth  nerve  in  the  floor  of  the  fourth 
ventricle.  Not  only  are  the  nerve  cells^  connected 
with  the  eyeball  disturbed,  but  the  neighbouring 
cells  also  are  affected,  and  by  a  psychical  error 
the  pain  is  reflected  along  the  nerves  with  which 
they  are  connected.  There  is  pain  over  the  fore- 
head along  the  supratrochlear,  supraorbital,  and 
lachrymal  branches  (circumorbital  pain),  and 
pain  down  the  side  of  the  nose  following 
the  nasal  nerve.  Or  the  pain  may  spread  to 
the  second  division  of  the  fifth,  and  discom- 
fort be  felt  in  the  temporal  region  (orbital 
branch  of  second  division),  or  be  referred  to 
the  upper  jaw  and  teeth.  These  affections  are 
associated  also  with  much  lachrymation,  the 
lachrymal  gland  being  also  supplied  through  the 
first  division  of  the  fifth.  Photophobia,  or  intoler- 
ance of  light,  is  common  in  inflammatory  affec- 
tions of  the  eye.  In  this  condition  there  is  spasm 
of  the  orbicular  muscle,  keeping  the  eye  closed, 
or  closing  it  on  the  least  exposure  to  irritation. 
Although  the  orbicular  muscle  is  supplied  by  the 
facial  nerve,  its  nerve  fibres  are  derived,  not  from 
the  nucleus  of  the  seventh  but  from  the  oculo- 
motor  nucleus,    situated   near   the   upper   sensory 


Chap.  IV]  THE    ORBIT  AND  EYE  65 

nucleus  of  the  fifth,  and  connected  with  it  by 
reflex  paths.  Photophobia  is  most  marked  in 
superficial  affections  of  the  cornea,  and  is  often 
much  benefited  by  a  seton  in  the  temporal  region. 
Inflammation  of  the  iris  and  glaucoma  are  accom- 
panied by  hyperesthesia  and  referred  pains  over 
the  outer  frontal  and  anterior  temporal  areas 
(Head).  The  nerve  centres  for  the  skin  of  this 
region  and  the  eyeball  are  closely  connected,  a 
relationship  which  may  explain  the  application 
of  counter-irritation  to  the  temples  in  eye  disease. 
Inflammation  of  the  cornea  gives  rise  to  no 
referred  pains  (Head).  Strain  of  the  ciliary 
muscle,  which  occurs  with  errors  of  refraction,  is 
one  of  the  commonest  causes  of  headache  leading 
to  referred  pains  and  areas  of  hyperesthesia  over 
the  mid-orbital  region  of  the  forehead. 

The  relations  between  the  nasal  nerve  and  the 
orbital  contents  receive  many  illustrations  in  prac- 
tice. Thus,  if  the  front  of  the  nose  be  struck,  or  the 
skin  over  its  lower  part  be  irritated,  as  by  squeez- 
ing a  painful  boil,  profuse  lachrymation  will 
frequently  be  produced.  Snuff,  too,  by  stimulating 
the  nasal  branch  of  the  ophthalmic  nerve,  often 
makes  the  eyes  of  the  uninitiated  to  water ;  and 
it  is  well  known  that  there  are  many  disturb- 
ances about  the  nose,  and  the  anterior  part  of  the 
nasal  fossse,  that  can  "  make  the  eyes  water." 
Herpes  zoster  often  provides  a  remarkable  illus- 
tration of  the  intimate  relation  between  the  nasal 
nerve  and  the  eye.  In  this  affection,  when  the 
regions  of  the  supraorbital  and  supratrochlear 
branches  of  the  first  division  are  alone  implicated, 
the  eye  is  usually  unaffected;  but  when  the  erup- 
tion extends  over  the  part  supplied  by  the  nasal 
nerve, _  i.e.  runs  down  the  side  of  the  nose,  then 
there  is  very  commonly  some  inflammation  of  the 
eyeball.  In  frontal  neuralgia  watering  of  the  eye 
(irritation  of  the  lachrymal  branch)  is  very  fre- 
quently met  with. 

The  dangerous  area  of  the  eye. — Penetrat- 
ing wounds  of  the  cornea  alone,  or  of  the  sclerotic 
F 


66  SURGICAL    APPLIED    ANATOMY         [Part  I 

alone,  behind  the  ciliary  region,  are  by  no  means 
serious  :  but  wounds  involving  the  ciliary  body, 
or  its  immediate  vicinity,  are  apt  to  assume  the 
gravest  characters.  Inflammation  in  the  ciliary 
region  is  peculiarly  obnoxious,  on  account  of  the 
important  vascular  and  nerve  anastomoses  that 
take  place  in  the  part.  Indeed,  as  regards  blood 
and  nerve  supply,  there  is  no  more  important 
district  in  the  eyeball.  From  the  ciliary  body 
also  inflammations  can  spread,  more  or  less 
directly,  to  the  cornea,  iris,  choroid,  vitreous,  and 
retina.  Plastic,  or  purulent,  inflammation  of  the 
ciliary-  body,  after  injury,  is  the  usual  starting 
point  of  sympathetic  ophthalmia.  In  this  terri- 
ble affection  destructive  inflammation  is  set  up  in 
the  sound  eye,  which  is,  however,  not  usually 
involved  until  two  or  three  months  after  the  other 
eye  has  been  injured.  "  Although  at  present  the 
exact  nature  of  the  process  which  causes  sym- 
pathetic inflammation  is  unknown,  and  though 
its  path  has  not  been  fully  traced  out,  it  is  cer- 
tain (1)  that  the  change  starts  from  the  region 
most  richly  supplied  by  branches  of  the  ciliary 
nerves,  viz.  the  ciliary  body  and  iris ;  (2)  that  its 
first  effects  are  generally  seen  in  the  same  part  of 
the  sympathising  eye ;  (3)  that  the  exciting  eye  has 
nearly  always  been  wounded,  and  in  its  anterior 
part,  and  that  decided  plastic  inflammation  of  its 
uveal  tract  is  always  present ;  (4)  that  inflamma- 
tory changes  have  in  some  cases  been  found  in  the 
ciliary  nerves  and  optic  nerve  of  the  exciting 
eye  "  (Nettleship).  It  is  now  generally  believed 
that  the  sound  eye  is  directly  infected  from  the 
diseased  one.  The  subarachnoid  spaces  which  sur- 
round the  optic  nerves  are  in  continuity  at  the 
chiasma,  and  offer  a  path  whereby  infection  may 
spread  from  one  eye  to  the  other. 

The  lens  measures  ^  of  an  inch  from  side  to 
side,  and  \  of  an  inch  from  before  backwards. 
All  through  life  it  slowly  increases  in  size.  It, 
together  with  its  capsule,  is  in  all  parts  perfectly 
transparent  and  perfectly  non-vascular.     The  lens 


Chap.  IV]  THE    ORBIT  AND  EYE  67 

may  easily  be  loosened  or  displaced  by  partial 
rupture  of  its  suspensory  ligament,  and  may  find 
its  way  into  the  anterior  chamber,  or,  more  com- 
monly, back  into  the  vitreous.  The  lens,  if  dis- 
turbed, may  swell,  and  by  the  pressure  thus  exer- 
cised cause  great  damage  to  the  important  struc- 
tures adjacent  to  it.  The  capsule  is  very  brittle 
and  elastic,  and  when  torn  its  edges  curl  out- 
wards. It  has  to  be  lacerated  in  all  cataract 
operations,  and  may  be  ruptured  by  many  forms 
of  violence  applied  to  the  eyeball.  When  the 
capsule  is  wounded  the  aqueous  humour  enters, 
and  is  imbibed  by  the  lens  fibres,  which  in  conse- 
quence swell  up  and  become  opaque,  thus  produc- 
ing a  traumatic  cataract.  In  the  various  forms  of 
cataract  the  whole  lens,  or,  more  commonly,  some 
portion  of  it,  becomes  the  seat  of  opacity.  This 
often  commences  in  the  nucleus,  and  for  a  long 
while  remains  limited  to  that  part;  or  it  may  first 
involve  the  cortex,  and  in  such  a  case  the  opacity 
takes  the  form  of  a  series  of  streaks  that  point  to- 
wards the  axis  of  the  lens,  and  are  dependent  upon 
the  arrangement  of  the  lens  fibres.  "  In  so-called 
'  concussion  cataract,'  where  after  a  blow  on  the 
eye  a  part  of  the  lens  becomes  opaque,  it  appears 
probable  that  the  capsule  has  been  very  slightly 
torn  opposite  to  the  opacity  "  (Lawford). 

Of  the  retina  it  is  only  necessary  to  observe 
that  its  connection  with  the  choroid  is  so  slight, 
that  it  may  easily  be  detached  from  that  mem- 
brane by  hsemorrhagic  or  other  effusions,  and  may 
indeed  be  so  detached  by  a  simple  blow  upon  the 
globe.  Even  when  extensively  detached  it  remains, 
however,  as  a  rule,  attached  at  both  the  optic  disc 
and  the  ora  serrata.  The  optic  nerve  as  it  passes 
from  the  brain  receives  its  perineural  sheath  from 
the  pia  mater,  and,  in  addition,  two  other  sheaths  : 
an  outer  from  the  dura  mater,  and  an  inner  from 
the  arachnoid.  These  sheaths  remain  distinct  and 
separate,  and  the  two  spaces  enclosed  may  be  in- 
jected, the  outer  from  the  subdural,  the  inner  from 
the  subarachnoid  space.     Thus  inflammatory  affec- 


68 


SUEGMCAL   APPLIED    ANATOMY       [Part  I 


tions  of  the  cerebral  meninges  can  readily  extend 
along  the  optic  nerve  to  the  optic  disc  through 
these  spaces  in  the  nerve  sheath,  while  in  cases  of 
intracranial  disease  other  than  meningeal  the 
mischief  may  extend  from  the  brain  to  the  disc 
along  the  interstitial  connective  tissue  in  the  nerve. 


Fig.  15. — Section  of  globe,  showing  iris,  lens,  ciliary  region,  etc. 
(After  Allen  Thomson.) 

a,  Cornea;  b,  sclerotic;  c,  lens;  d,  iris;  e,  ciliary  process ;  /,  conjunctiva;  fir,  cana 
of  Schlerain ;  h,  canal  of  Petit ;  i,  hyaloid  membrane ;  j,  choroid  covered  by 
retina ;  k,  aqueous  chamber. 


These  connections  may  serve  in  part  to  explain  the 
frequent  association  of  optic  neuritis  with  intra- 
cranial disease.  Optic  neuritis  usually  implies  that 
the  optic  disc  or  papilla  is  inflamed,  but  in  excep- 
tional cases  the  changes  are  limited  to  that  part  of 
the  nerve  behind  the  globe  (retrobulbar  neuritis). 
The  length  of  the  optic  nerve  within  the  orbit  is 
28  to  29  mm. 


Chap.  IV]  THE    ORBIT  AND  EYE  69 

The     aqueous     and    vitreous    humours. — 

The  aqueous  fills  the  space  between  the  capsule 
and  suspensory  ligament  of  the  lens  and  the  cornea. 
The  iris  divides  this  space  into  two  parts,  the  an- 
terior and  posterior  chambers.  Since,  however,  the 
iris  is  largely  in  actual  contact  with  the  lens,  it 
happens  that  the  posterior  chamber  is  repre- 
sented by  a  little  angular  interval  between  the 
iris,  the  ciliary  processes,  and  the  suspensory 
ligament  of  the  lens  (Fig.  15).  The  depth  of 
the  anterior  chamber  is  3'6  mm.  The  cornea 
at  its  circumference  breaks  up  into  bundles  of 
fibres,  which  are  partly  continued  into  the  front  of 
the  iris,  and  which  constitute  the  ligamentum  pec- 
tinatum  iridis.  Between  the  processes  of  this  liga- 
ment there  are  intervals  which  lead  into  certain 
cavernous  spaces  called  the  spaces  of  Fontana. 
These  spaces  in  their  turn  communicate  with  a 
large  circular  canal  situate  in  the  sclerotic  close 
to  its  junction  with  the  cornea,  and  known  as  the 
canal  of  Schlemm  (Fig.  15,  g).  This  space  is  in 
communication  with  the  veins  of  the  anterior  part 
of  the  sclerotic,  and  thus  through  this  somewhat 
complicated  channel  the  aqueous  chamber  is 
brought  into  relation  with  the  venous  circulation 
This  relation  probably  explains  the  ready  absorp- 
tive powers  of  the  aqueous.  Thus,  if  pus  finds  its 
way  into  the  anterior  chamber  (hypopyon)  it  is 
usually  readily  absorbed.  The  same  applies  to 
moderate  extravasations  of  blood  in  the  chamber, 
and  the  speedy  removal  of  such  effusions  contrasts 
with  the  difficulty  that  is  experienced  in  the  absorp- 
tion of  blood  from  the  vitreous  chamber.  The 
treatment  of  soft  cataracts  by  the  "  needle  opera- 
tion "  depends  for  its  success  upon  the  absorptive 
powers  of  the  aqueous.  In  this  procedure,  the  lens 
capsule  having  been  torn  through,  and  the  cataract 
hrokenup  with  needles,  the  removal  of  the  opaque 
debris  is  left  to  the  aqueous,  and  it  is  not  long  be- 
fore  its   efficacy   in   that   direction   is   seen. 

The      vitreous     takes     little     active     share    in 
ocular  maladies.    It  may  be  secondarily  affected  in 


70  SUEGICAL   APPLIED    ANATOMY       [Part  I 

inflammation  of  adjacent  parts,  may  be  the  seat  of 
haemorrhages,  and  is  often  occupied  by  opaque 
bodies  of  various  kinds.  Foreign  bodies  have  lodged 
in  the  vitreous  for  considerable  periods  without 
causing  any  symptoms.  The  muscse  voHtantes  that 
so  often  trouble  the  myopic  are  due  to  little  opaque 
matters  in  the  vitreous,  and  very  often  have  exactly 
the  appearance  that  the  corpuscles  of  the  vitreous 
present  when  seen  under  the  microscope. 

The  delicate  transparent  membrane  which  en- 
capsules  the  vitreous  humour  is  known  as  the 
hyaloid  membrane.  The  vitreous  is  readily  separ- 
ated from  the .  retina  except  behind,  opposite  the 
disc  where  the  artery  to  the  lens  enters  in  the 
foetus. 

This  vessel  is  a  branch  of  the  central  artery  of 
the  retina,  and  may  persist  as  a  fibrous  cord  in 
adult  life.  In  some  rare  cases  it  has  continued  to 
transmit  blood,  and  in  such  instances  its  pulsation 
can  be  seen  with  the  ophthalmoscope. 

Glaucoma  is  a  disease  the  symptoms  of  which 
are  all  dependent  upon  an  increase  in  the  intraocu- 
lar tension  of  the  globe.  The  increased  tension  is 
due  to  an  excess  of  fluid  within  the  eyeball,  and 
this  would  appear  to  result  from  certain  changes, 
seldom  absent  in  the  glaucomatous,  that  interfere 
with  the  normal  escape  of  this  fluid.  Normally 
there  is  a  constant  movement  of  fluid  through  the 
pupil  from  the  posterior  to  the  anterior  chamber. 
This  fluid  is  derived  mainly  from  the  ciliary  bodies, 
and  in  a  less  degree  from  the  posterior  surface  of 
the  iris.  Atrophy  of  the  epithelium  on  the  ciliary 
body  is  said  to  lead  to  diminished  tension^  From 
the  anterior  chamber  the  fluid  can  escape  into  the 
veins  through  the  gaps  in  the  ligamentum  pectin- 
atum  already  alluded  to  (Fig.  15).  It  is  remark- 
able that  in  nearly  every  case  of  glaucoma  these 
gaps  are  occluded  by  the< complete  obliteration  of 
the  angle  between  the  periphery  of  the  iris  and  the 
cornea,  which  angle  is  normally  occupied  by  the 
ligamentum  pectinatum.  The  importance  of  the 
peripheral  part  of  the  anterior  chamber  in  relation 


Chap.  IV]  THE   ORBIT  AND  EYE  71 

to  the  outflow  of  fluid  from  the  eye  is  shown  in 
many  ways.  If  this  part  be  blocked  by  the  iris  in 
perforation  of  the  cornea,  or  by  the  lens  in  some 
dislocations  of  that  body,  increased  tension  of  the 
globe  is  apt  to  follow.  The  relief  given  to  glaucoma 
by  iridectomy  appears  to  depend  upon  the  circum- 
stance that  the  operation  practically  opens  up 
again  these  channels  of  communication  from  the 
aqueous,  since  the  procedure,  to  be  successful, 
should  involve  an  incision  so  far  back  on  the  sclero- 
tic as  to  fully  pass  through  the  angle  just  alluded 
to.  It  is  needful  also  that  the  iris  should  be  re- 
moved quite  up  to  its  attachment,  and  that  the 
portion  resected  should  be  considerable. 

The  symptoms  of  glaucoma  are  all  explained 
by  the  effects  of  the  abnormal  tension.  Thus,  the 
ciliary  nerves  are  compressed  against  the  unyield- 
ing sclerotic,  and  give  rise  to  intense  pain,  while 
the  disturbance  in  their  functions  shows  itself 
in  the  fixed  and  dilated  pupil  and  in  the  anaes- 
thetic cornea.  Perhaps  the  first  parts  to  suffer 
from  compression  are  the  retinal  blood-vessels, 
and  the  effect  upon  them  will  be  most  obvious  at 
the  periphery  of  the  retina,  i.e.  at  the  extreme 
limit  of  the  retinal  circulation.  Hence  follows 
that  gradual  narrowing  of  the  visual  field  which  is 
constant  in  glaucoma,  while  the  pressure  upon  the 
optic  nerve  produces  those  flashes  of  light  and 
other  spectra  which  occur  in  the  disease.  The 
weakest  part  of  the  sclerotic  is  in  the  disc  at  the 
lamina  cribrosa.  This  part  rapidly  yields  under 
the  pressure,  and  so  produces  the  "  glaucomatous 
cup.;;  Pressure  in  the  opposite  direction  pushes 
the  lens  forward,  and  thus  narrows  the  anterior 
chambers ;  while  the  general  interference  with  the 
ocular  circulation  is  shown  in  the  distended 
vessels  that  appear  upon  the  globe. 

The  eyelids. — The  skin  over  the  eyelids  is  ex- 
tremely thin  and  delicate,  and  shows  readily 
through  its  substance  any  extravasation  of  blood 
that  may  form  beneath  it.  Its  laxity,  moreover, 
renders  it  very  well   adapted  for  certain  plastic 


72  SURGICAL   APPLIED    ANATOMY       [Part  I 

operations  that  are  performed  upon  the  part.  Its 
loose  attachments  cause  it  to  be  readily  influenced 
by  traction,  and  the  shrinking  of  cicatrices  below 
the  lower  lid  is  very  apt  to  draw  that  fold  away 
from  the  globe,  and  so  produce  the  condition  of 
eversion  of  the  lid  known  as  ectropion.  The  con- 
traction of  the  conjunctiva  after  inflammatory  con- 
ditions, or  after  it  has  been  subjected  to  destructive 
agencies,  is  prone,  on  the  other  hand,  to  curl  either 
lid  inwards  towards  the  globe,  and  thus  to  produce 
entropion.  Tlie  lids  present  many^  transverse 
folds  ;  one  of  these  on  the  upper  lid,  deeper  and 
more  marked  than  the  rest,  divides  the  lid  into 
two  parts,  the  part  below  being  that  which  covers 
the  globe,  the  part  above  being  that  in  relation 
with  the  soft  structures  of  the  orbit.  In  emacia- 
tion the  lid  becomes  much  sunken  in  the  line  of 
this  fold.  Incisions  should  follow  the  direction  of 
these  folds.  The  lids  are  very  freely  supplied  with 
blood,  and  are  often  the  seat  of  nsevi  and  other  vas- 
cular growths.  ^  Rodent  ulcer  so  frequently  attacks 
this  part  that  it  was  originally  known  as  "  Jacob's 
ulcer  of  the  eyelid." 

The  following  layers  are  found  in  either  lid  in 
order  :  (1)  the  skin;  (2)  the  subcutaneous  tissue; 
(3)  the  orbicularis  palpebrarum;  (4)  the  tarsal 
plate  and  its  continuation  to  the  margin  of  the  or- 
bit-rthe<  palpebral  membrane;  (5)  the  layer  of 
Meibomian  glands  embedded  in  the  plate ;  and  (6) 
the  conjunctiva.  In  the  upper  lid  the  levator  pal- 
pebrse  is  found  passing  to  the  tarsal  plate.  The 
subcutaneous  tissue  is  very  lax,  and  hence  the  lids 
swell  greatly  when  oedematous,  or  when  inflamed, 
and  when  the  seat  of  haemorrhage.  On  this  ac- 
count it  is  inadvisable  to  apply  leeches  to  the  lids, 
because  of  the  extensive  black  eye"  that  may 
follow.  This  tissue  is  peculiar  in  containing  no 
fat.  At  the  edge  of  the  lids  are  found  the  eye- 
lashes, the  orifices  of  the  Meibomian  glands,  and 
of  some  modified  sweat  and  sebaceous  glands.  The 
secretion  of  these  glands  prevents  adhesion  of  the 
edges  of  the  lid.     This  edge,  like  other  points  of 


Chap.  IV] 


THE   ORBIT  AND  EYE 


73 


junction  of  skin  and  mucous  membrane,  is  apt  to 
be  the  seat  of  irritative  affections.  Being  a  free 
border  also,  the  circu- 


l 


lation  is  terminal,  and 
stagnation  in  the 
blood  current  is  not 
difficult  to  produce. 
Sycosis,  an  inflamma- 
tion involving  the  hair 
follicles  and  some  of 
the  glands  at  the  edge 
of  the  lid,  is  among 
the  most  common  of 
ophthalmic  affections. 
The  common  stye  also 
is  a  suppuration  in 
the  connective  tissue 
or  in  one  of  the  glands 
at  the  margin.  On 
everting  the  lid  the 
Meibomian  glands  can 
be  seen  through  the 
conj  unctiva  as  lines 
of  yellowish  granules. 
The  common  tarsal 
cyst  is  a  retention 
cyst  developed  in  one 
of  these  glands. 

Two  arteries  sup- 
ply either  lid  :  a  pal- 
pebral   branch   of   the 

Ophthalmic         running    Fig1. 16.— Vertical  section  through  upper 

along  the  inner  part,  eyelid-    (After  Waideyer.) 

nnrJ      a     hy^-nnh     r»f     +V10    «.  Skin  ;  b,  orbicularis  ;   ¥,  its  ciliary  part : 

d/iiu.     a,     ui  dutu     UJ.     i/iie  c,  involuntary  muscle  of  eyelid  repre- 

lachrymal      along      the  senting  part  of  the   insertion   of  the 

,       a          .       P         R     ,.  ,  levator    palpebrse;   d,    conjunctiva;   e, 

OUter   part  OI  each  lid.  tarsal  cartilage  ;  /,  Meibomian  gland; 

F„.  „       „                                  i  a,  modified  sweat  gland ;  /(,  eyelashes 

OUr       nerves       Supply  v,'Post-tarsalglands 

the   upper   eyelid,   the 

supraorbital,  the  supratrochlear  and  infratroch- 
lear,  and  the  lachrymal.  One  nerve  supplies  the 
lower  lid,  the  infraorbital.  Some  of  the  lymph- 
atics of  the  eyelids  enter  the  preauricular  glands, 


74  SURGICAL   APPLIED   ANATOMY      [Part  I 

hence  in  cases  of  chancre  of  the  lid  the  glandular 
enlargement  has  nearly  always  been  noticed  in 
front  of  the  parotid  gland  (Fig.  35,  p.  190). 

The  conjunctiva. — The  ocular  Dart  of  this 
membrane  is  thin,  covered  with  stratified  epithe- 
lium very  loosely  attached,  and  not  very  exten- 
sively supplied  with  blood;  the  palpebral  portion 
is  thicker,  covered  with  columnar  epithelium  more 
closely  adherent,  and  more  vascular.  At  the  edge 
of  the  cornea  the  conjunctiva  becomes  continuous 
with  the  epithelium  covering  that  tunic.  The  loose- 
ness of  the  ocular  conjunctiva  allows  it  to  be  freely 
moved  about,  and  is  of  great  value  in  some  opera- 
tions, as,  for  example,  in  Teale's  operation  for 
symblepharon,  where  a  bridge  of  conjunctiva,  dis- 
sected up  from  the  globe  above  the  cornea,  is  drawn 
down  over  the  cornea  to  cover  a  raw  surface  in  con- 
tact with  the  lower  lid.  This  lax  tissue  favours  the 
development  of  oedema  (chemosis),  which  in  ex- 
treme cases  may  reach  such  a  degree  that  the 
patient  cannot  close  his  eye.  The  vessels  also, 
being  feebly  supported,  are  prone  to  give  way 
under  no  great  provocation.  Thus,  subconjunc- 
tival haemorrhages  may  occur  from  severe  vomit- 
ing, or  during  a  paroxysm  of  whooping  cough. 
Blood  also  may  find  its  way  beneath  the  membrane 
in  fractures  of  the  base  of  the  skull.  Haemorrhages 
beneath  the  membrane  are  unlike  other  extravasa- 
tions (bruises),  in  that  they  retain  their  scarlet 
colour.  This  is  due  to  the  fact  that  the  thinness 
of  the  conjunctiva  allows  oxygen  to  reach  the  blood 
and  retain  for  it  an  arterial  character.  Severe 
inflammation  of  the  conjunctiva^  may  lead  to  con- 
siderable cicatricial  changes,  as  is  the  case  in  other 
mucous  membranes,  and  especially,  perhaps,  in 
the  urethra.  The  contraction  of  the  conjunctiva 
after  destructive  processes  is  apt  to  lead  to  en- 
tropion. If  both  the  ocular  and  the  corresponding 
part  of  the  palpebral  conjunctiva  have  been  de- 
stroyed, the  two  raw  surfaces  left  will  readily  ad- 
here ;  the  lid  will  become  fused  to  the  globe,  and 
the   condition   called   symblepharon  be   produced. 


Chap.  IV]  THE    OEBIT  AND  EYE  75 

This  condition  concerns  the  lower  lid,  and  is  gener- 
ally brought  about  by  lime  or  other  caustics  being 
accidentally  introduced  between  the  under  lid 
and  the  globe. 

In  one  common  form  of  inflammation  of  this 
membrane  a  number  of  little  "  granulations  "  ap- 
pear upon  the  palpebral  conjunctiva.  These  are 
not  real  granulations,  since  no  true  ulceration  of 
the  part  takes  place,  but  they  appear  to  be  made 
up,  some  of  nodules  of  adenoid  tissue,  others  of 
enlarged  mucous  follicles  and  of  hypertrophied 
papillae,  all  of  which  structures  are  normally  found 
in  the  membrane.  The  condition  is  known  as 
"granular  lids,"  and  is  associated  with  the  forma- 
tion of  much  new  tissue  in  the  deeper  parts  of  the 
membrane.  From  the  absorption  of  this  new 
tissue  and  of  these  granulations  a  contracting  cica- 
trix results,  leading  to  much  puckering  of  the 
membrane,  and  often  to  entropion  and  inversion 
of  the  eyelashes.  In  purulent  ophthalmia  the 
cornea  is  in  great  risk  of  destruction,  owing  to 
the  strangulation  of  its  vessels  and  possibly  to  the 
direct  effects  of  the  discharge  upon  the  membrane. 

The  lachrymal  apparatus. — The  lachry- 
mal gland  is  invested  by  a  special  fascia  which 
separates  it  from  the  general  cavity  of  the  orbit; 
and,  according  to  Tillaux,  this  little  body  can  be 
removed  without  opening  the  greater  space  of  the 
orbit.  The  gland  may  inflame,  and  become  so  en- 
larged as  to  appear  as  a  tumour,  which  may  dis- 
place the  globe  downwards  and  inwards,  and  press 
forwards  the  oculo-palpebral  fold  of  conjunctiva. 
If  an  abscess  forms,  it  most  usually  breaks  through 
the  skin  of  the  upper  lad.  Cystis  of  the  gland 
(dacryops)  are  due  to  obstruction  and  distension 
of  some  of  its  ducts.  The  normal  secretion  of  the 
gland  keeps  the  exposed  surface  of  the  eye  moist, 
yet  the  gland  may  be  excised  without  giving  rise 
to  any  untoward  effect. 

The  lachrymal  sac  is  situated  at  theside  of  the 
nose,  near  the  inner  canthus,  and  lies  in  a  groove 
on    the    lachrymal    and  superior  maxillary  bones 


7fi 


SUEGICAL   APPLIED    ANATOMY       [Part  t 


(Fig.  17).  On  its  outer  side,  and  a  little  anteriorly, 
it  receives  the  two  lachrymal  canaliculi.  In  front 
of  the  sac  is  the  tendo  oculi.  If  the  two  lids  be 
forcibly  drawn  outwards  this  tendon  can  be  readily 
felt  and  seen,  and  serves  as  a  guide  to  the  sac.     It 


Lacm. Gland 
Plica  Semiluaj. 
/^asioai 
Canaliculus 

1/mt.  Tarsal  Lie. 
Lac/i.  5ac 

/IasalDuct 


A1P  /TEATUS 


Fig.  17. — Diagram  of  the  lachrymal  apparatus. 
The  arrow  points  to  the  first  molar  tooth,  showing  the  direction  of  the  nasal  duct 

can  also  be  felt  as  it  is  tightened,  when  the  lids  are 
firmly  closed.  It  crosses  the  sac  at  right  angles, 
and  at  about  the  junction  of  its  upper  third  with 
its  lower  two-thirds.  A  knife  entered  immediately 
below  the  tendon  would  about  open  the  middle  of 
the  sac,  and  it  may  be  noted  that  a  lachrymal 
abscess,   when   about  to   discharge,   always  points 


Chap.  IV]  THE    ORBIT  AND  EYE  77 

below  the  tendon.  Epiphora,  or  overflow  of  tears, 
is  due  in  the  main  to  two  causes  :  (1)  to  an  obstruc- 
tion in  any  part  of  the  lachrymal  passages  from  the 
puncta  to  the  opening  of  the  nasal  duct  in  the 
nose;  (2)  to  any  cause  that  removes  the  lower 
punctum  from  its  contact  with  the  globe,  as  may  be 
the  case  in  ectropion,  in  entropion,  in  swelling  of 
the  lower  lid,  etc.  Facial  palsy  causes  epiphora, 
because,  the  orbicular  muscle  being  relaxed,  the 
punctum  falls  away  from  the  globe,  and,  more- 
over, the  passage  of  the  tears  is  no  longer  aided 
by  the  suction  action  effected  by  the  muscle  in  the 
process  of  winking.  The  canaliculi  may  readily  be 
slit  up  by  a  proper  knife,  and  a  probe  can  without 
difficulty  be  passed  down  the  nasal  duct  from  the 
lachrymal  sac. 

The  nasal  duet  is  a  little  over  £  an  inch  in 
length,  and  the  probe  that  traverses  it  should  pass 
downwards,  and  a  little  backwards  and  outwards, 
in  the  direction  of  the  first  molar  tooth  (Fig.  17). 
The  nasal  duct  perforates  the  mucous  membrane  of 
the  nose  below  the  inferior  turbinate  process  very 
obliquely,  so  that  its  inner  wall  acts  as  a  valve.  If 
this  is  destroyed  by  ulceration,  as  sometimes  oc- 
curs in  syphilis,  the  lachrymal  sac  may  be  inflated 
by  blowing  the  nose.  The  bony  nasal  duct  has  a 
calibre  which  varies  from  2*5  to  7*5  mm.  in  dia- 
meter ;  the  thick  mucous  membrane  which  lines 
it  has  a  rich  venous  plexus  in  its  submucous  layer 
which  readily  swells  and  prevents  the  passage  of 
tears  when  the  duct  is  inflamed.  The  normal  duct 
will  take  a  probe  measuring  35  mm.  in  diameter ; 
it  must  be  remembered  that  the  lumen  of  the  duct 
is  normally  closed,  and  that  its  lining  membrane 
possesses  several  transverse  folds  which  may  catch 
the  point  of  a  probe.  Inflammatory  conditions 
readily  ascend  from  the  nasal  cavity  to  the  lachry- 
mal sac  through  the  nasal  duct. 

As  affections  of  the  lachrymal  sac  are  often  very 
painful,  it  may  be  noted  that  the  nerve  supply  of 
the  sac  is  derived  from  the  infratrochlear  branch 
of  the  nasal  nerve. 


CHAPTER   V 
THE   EAE 

The    pinna,    and    external    auditory   meatus. 

— The  pinna  may  be  congenitally  absent,  or  may 
be  supplemented  by  supernumerary  portions  of  the 
auricle,  which  may  be  situated  upon  the  cheek  or 
side  of  the  neck.  In  the  latter  situation  the  so- 
called  supernumerary  auricle  consists  in  an  irregu- 
lar leaf  of  fibro-cartilage  developed  from  the  mar- 
gins of  one  of  the  lower  branchial  clefts.  (See 
p.  193.)  The  tag-like  supernumerary  auricles  that 
are  found  on  the  cheek  just  in  front  of  the  pinna 
or  meatus  are  due  to  the  irregular  development  or 
want  of  fusion  of  one  or  more  of  the  six  tubercles 
from  which  the  pinna  itself  is  developed.  The  pinna 
may  present  a  congenital  fistula  dependent  on  a 
defective  closure  of  the  first  branchial  cleft.  The 
position  of  this  cleft  is  represented  in  the  normal 
ear  by  the  Eustachian  tube,  the  tympanum,  and 
the  external  auditory  meatus,  the  pinna  being 
developed  from  the  integument  bordering  the  cleft. 
In  these  congenital  fistulse,  when  well  marked,  the 
pinna  is  cleft  above  or  below  the  meatus.  Some 
of  the  smaller  and  more  superficial  fistulse  are  due 
not  to  a  defective  closure  of  the  branchial  cleft  but 
to  want  of  complete  fusion  between  certain  of  the 
tubercles  from  which  the  pinna  is  primarily  de- 
veloped. Accidental  removal  of  the  pinna  is 
usually  associated  with  but  comparatively  little 
diminution  in  the  acuteness  pi  hearing. 

The  skin  covering  the  auricle  is  thin  and  closely 

78 


Chap.  V]  THE    EAR  79 

adherent.  The  subcutaneous  tissue  is  scanty,  and 
contains  but  very  little  fat.  In  inflammatory  con- 
ditions of  the  surface,  such  as  erysipelas,  the 
pinna  may  become  extremely  swollen  and  very 
great  pain  be  produced  from  the  tenseness  of  the 
parts.  The  pinna  and  cartilaginous  meatus  are 
very  firmly  attached  to  the  skull,  so  that  the  body, 
if  not  of  great  weight,  may  be  lifted  from  the 
ground  by  the  ears. 

The  external  auditory  meatus  is  about 
1|  inches  long.  It  is  important  to  remember  that 
the  meatus  is  directed  forwards  as  well  as  inwards  ; 
to  reach  and  expose  the  middle  ear  the  surgeon 
takes  the  posterior  wall  of  the  meatus  as  a  guide. 
The  external  meatus,  the  promontory,  the  cochlea, 
and  the  internal  meatus  lie  nearly  in  the  same  line. 
The  canal  has  a  vertical  curve  about  its  middle, 
with  the  convexity  upwards.  To  straighten  the 
canal  for  the  introduction  of  specula  and  other  in- 
struments, the  pinna  should  be  drawn  upwards  and 
a  little  outwards  and  backwards.  The  osseous  part 
forms  a  little  more  than  one-half  of  the  tube,  and  is 
narrower  than  the  cartilaginous  part. 

In  the  infant  at  one  year,  a  third  only  of  the 
meatus  is  formed  of  bone.  The  rest  is  cartilagin- 
ous. In  a  child  of  five  or  six  years  of  age  the  bony 
and  cartilaginous  portions  of  the  meatus  are  about 
of  the  same  length  (Symington).  The  meatus  is  re- 
latively as  long  in  a  child  as  it  is  in  an  adult.  The 
narrowest  portion  of  the  meatus  is  about  its  mid- 
dle. The  outer  orifice  is  elliptical,  with  its  great- 
est diameter  directed  from  above  downwards ; 
therefore  specula  should  be  elliptical  in  shape 
rather  than  round.  The  inner  end  of  the  tube,  on 
the  other  hand,  is  slightly  wider  in  the  transverse 
direction.  Owing  to  the  obliquity  of  the  mem- 
brana  tympani,  the  floor  of  the  meatus  is  longer 
than  the  roof.  The  cartilaginous  segment  of  the 
tube  presents  many  sebaceous  glands  that  may  be 
the  seat  of  minute  and  very  painful  abscesses.  It 
also  presents  numerous  ceruminous  glands,  which 
secrete  the  cerumen  of  the  ear,  and  which,  when 


80  SUEGMCAL   APPLIED    ANATOMY       [Part  I 

their  secretion  is  excessive,  may  produce  the  plugs 
of  wax  that  often  block  the  meatus  and  cause  deaf- 
ness. In  the  cartilage  of  the  floor  of  the  meatus 
are  certain  fissures,  fissures  of  Santorini.  They  are 
filled  up  with  fibrous  tissue.  They  permit  of  easier 
movement  of  the  cartilaginous  meatus.  It  is 
through  these  gaps  in  the  cartilage  that  a  parotid 
abscess  may  burst  into  the  meatus.  There  are 
neither  hairs  nor  glands  in  the  lining  of  the  bony 
part  of  the  tube. 

The  skin  of  the  meatus,  when  inflamed,  may  pro- 
duce an  extensive  muco-purulent  discharge,  otitis 
externa.  Polypi  are  apt  to  grow  from  the  soft  parts 
of  the  canal,  and  exostoses  from  its  bony  wall. 
Foreign  bodies  are  frequently  lodged  in  the 
meatus,  and  often  involve  great  difficulties  in  their 
extraction.  It  would  appear  that  in  many  cases 
more  damage  is  done  by  the  surgeon  than  by  the 
intruding  substance.  Mason  reports  three  cases 
where  a  piece  of  slate-pencil,  a  cherry-stone,  and  a 
piece  of  cedar-wood  were  lodged  in  the  canal  for 
respectively  forty  years,  sixty  years,  and  thirty 
years. 

The  upper  wall  of  the  meatus  is  in  relation  with 
the  cranial  cavity,  from  which  it  is  only  separated 
by  a  dense  layer  of  bone.  Thus,  abscess  or  bone  dis- 
ease in  this  part  may  possibly  lead  to  meningitis. 
A  case  is  reported  where  an  inflammation  of  the 
cerebral  membrane  followed  upon  the  retention 
of  a  bean  within  the  meatus.  The  anterior  wall 
of  the  canal  is  in  relation  with  the  temporo- 
maxillary  joint  and  with  part  of  the  parotid 
gland.  This  may  serve  in  one  way  to  explain  the 
pain  often  felt  in  moving  the  jaw  when  the 
meatus  is  inflamed,  although,  at  the  same  time,  it 
must  be  remembered  that  movement  of  the  lower 
maxilla  produces  a  movement  in  the  cartilagin- 
ous meatus,  and  that  both  the  canal  and  the  joint 
are  supplied  by  the  same  nerve  (the  auriculo- 
temporal). From  its  relation  to  the  condyle  of 
the  jaw,  it  follows  that  this  wall  of  the  meatus  has 
been  fractured  by  that  condyle  in  falls  upon  the 


Chap.  V]  THE    EAR  81 

chin.  Tillaux  states  that  abscess  in  the  parotid 
gland  may  spread  into  the  meatus  through  the  an- 
terior wall  of  the  passage.  The  posterior  wall  separ- 
ates the  meatus  from  the  mastoid  cells.  Directly 
behind  the  posterior  wall,  at  a  distance  of  12  or  15 
mm.,  is  the  lateral  sinus  (Fig.  20).  The  inferior 
wall  of  the  bony  meatus  is  very  dense  and  substan- 
tial, and  corresponds  to  the  vaginal  and  styloid 
processes. 

Blood  supply.  —  The  pinna  and  external 
meatus  are  well  supplied  with  blood  fay  the  tem- 
poral and  posterior  auricular  arteries,  the  meatus 
receiving  also  a  branch  from  the  internal  maxillary. 
In  spite  of  this  supply,  the  pinna  is  frequently  the 
seat  of  gangrene  from  frost-bite.  This^  is  due  to 
the  fact  that  all  the  vessels  are  superficial  and  lie 
close  beneath  the  surface,  that  the  part  is  much 
exposed  to  cold,  and  that  the  pinna  lacks  the  pro- 
tection of  a  covering  of  fat.  The  same  conditions 
predispose  to  gangrene  of  the  nose  from  external 
cold.  Bloody  tumours  (hsematomata)  are  often  met 
with  on  the  pinna,  and  are  common  in  boxers,  foot- 
ball players,  and  lunatics.  They  are  due  to  injury, 
and  consist  of  an  extravasation  between  the 
perichondrium  and  the  cartilage. 

Nerve  supply. — The  pinna  is  supplied  by 
the  auriculotemporal,  great  auricular  and  small 
occipital  nerves  (see  Fig.  4,  p.  15).  Arnold's  nerve, 
the  auricular  branch  of  the  vagus,  sends  a  twig  to 
the  back  of  the  concha,  near  the  mastoid  process. 
The  meatus  is  supplied  mainly  by  the  auriculo- 
temporal, with,  in  addition,  a  contribution  from 
Arnold's  nerve,  which  goes  to  the  lower  and  back 
part  of  the  canal,  not  far  from  its  commencement. 
Arnold's  nerve  has  been  credited  with  a  good  deal 
in  connection  with  the  nerve  relations  of  the  ear. 
After  a  heavy  dinner,  when  the  rose-water  comes 
round,  it  is  common  to  see  the  more  experienced 
of  the  diners  touch  the  lower  part  of  the  back  of 
the  ear  with  the  moistened  serviette.  This  is  said 
to  be  very  refreshing,  and  is  supposed  to  be  an 
unconscious  stimulation  of  Arnold's  nerve,  a  nerve 

G 


82  SURGICAL    APPLIED    ANATOMY       [Part  I 

whose  main  trunk  goes  to  the  stomach.  Hence, 
this  little  branch  has  been  facetiously  termed 
"the  alderman's  nerve. " 

Ear  coughing,  ear  sneezing,  ear  yawning. 

— It  is  not  uncommon  to  have  a  troublesome  dry 
cough  associated  with  some  mischief  in.  the 
meatus.  Sometimes  the  mere  introduction  of  a 
speculum  will  make  the  patient  cough.  A  case 
is  reported,  where  a  troublesome  cough  persisted 
for  eighteen  months,  and  at  once  ceased  on  the  re- 
moval of  a  plug  of  wax  from  the  ear.  In  such  cases 
the  irritation  is  conveyed  to  the  respiratory  and 
cough  centres  in  the  floor  of  the  fourth  ventricle  by 
Arnold's  nerve,  a  small  branch  of  the  vagus.  Gas- 
kell  has  shown  that  the  vagus  also  contains  the  dis- 
associated visceral  fibres  of  the  fifth  nerve.  Hence, 
disturbances  may  be  set  up  in  the  vagal  nuclei 
through  branches  of  the  fifth  nerve,  such  as  the 
auriculo-temporal.  The  connection  of  the  nerves 
of  the  external  auditory  meatus  with  the  vagal 
nuclei  also  explains  the  sneezing  or  vomiting  which 
is  sometimes  caused  by  the  presence  'of  foreign 
bodies  in  the  external  meatus.  The  same  nerve 
connection  also  explains  the  occurrence  of  repeated 
yawning,  sometimes  set  up  by  ear  ailments.  Irrita- 
tion conveyed  along  the  inferior  dental  or  lingual 
nerves  may  be  referred  along  the  auriculo-tem- 
poral. Hence  the  need  to  examine  the  tongue  and 
lower  teeth  in  cases  of  earache.  Head  has  pointed 
out  that  disease  of  the  ear,  the  tonsil,  the  tongue 
or  the  lower  jaw  may  be  associated  with  an  area 
of  tenderness  in  the  skin  along  and  below  the  jaw. 

It  is  a  common  practice  to  introduce  ear-rings 
with  the  idea  of  relieving  obstinate  affections  of  the 
eye.  No  anatomical  basis  can  be  offered  to  explain 
such  treatment.  The  lobule  is  supplied  by  the  great 
auricular  nerve  which  springs  from  the  second 
and  third  cervical  nerves,  while  the  eye  is  supplied 
by  the  ophthalmic  division  of  the  fifth.  The  lower 
sensory  nucleus  of  the  fifth  is  a  direct  continuation 
upwards  of  the  grey  matter  from  which  the  pos- 
terior roots  of  the  cervical  nerves  arise. 


Chap.  V]  THE    EAR  83 

Hilton  reports  a  case  of  obscure  pain  in  the  ear 
which  was  found  to  be  due  to  an  enlarged  gland  in 
the  neck,  that  pressed  upon  the  trunk  of  the  great 
auricular  nerve. 

Membra na  tympani. — This  membrane  is  very 
obliquely  placed,  forming  with  the  horizontal  an 
angle  of  45°.   At  birth  it  appears  to  be  more  nearly 


Fig.  IS. — Section  through  the  external  meatus,  middle  ear,  and  Eustachian 

tube.    (Tillaux.) 

a,  External  auditory  meatus ;  5,  attic  of  tympanum ;  c,  Eustachian  tube ; 
d,  internal  auditory  meatus;  e,  cochlea;  /,  ossicles;  g,  membrana  tympani;- 
ft,  styloid  process. 

horizontal,  although  it  is  not  really  so.  In  cretins, 
and  in  some  idiots,  it  is  said  to  retain  this  apparent 
inclination.  Owing  to  the  sloping  downwards  of 
the  bony  wall  of  the  meatus  at  its  inner  end,  that 
wall  forms  with  the  lower  edge  of  the  membrane 
a   kind   of   sinus   in    which   small   foreign   bodies 


84  SURGICAL    APPLIED    ANATOMY       [Part  I 

may  readily  lodge  (Fig.  18).  The  ring  of  bone  to 
which  the  membrane  is  attached  is  deficient  at  its 
upper  and  anterior  part.  The  gap  so  formed  is 
called  the  notch  of  Rivini,  and  is  occupied  by  loose 
connective  tissue,  covered  by  a  continuation  of  the 
lining  of  the  meatus,  and  through  it  pus  may  es- 
cape from  the  middle  ear  into  the  auditory  canal 
without  perforating  the  membrane.  When  the 
membrane  gives  way  owing  to  a  violent  concussion 
transmitted  through  the  air,  it  often  gives  way 
opposite  the  notch,  its  attachments  here  being  ob- 
viously less  secure  than  elsewhere.  The  membrane 
possesses  but  little  elasticity,  as  shown  by  the  very 
slight  gaping  of  the  part  after  it  has  been  wounded. 
It  is  for  this  reason,  among  others,  that  perfora- 
tions made  in  the  membrane  by  the  surgeon  heal 
so  very  rapidly.  The  membrane  has  been  ruptured 
during  tits  of  sneezing,  coughing,  vomiting,  etc. 
The  same  lesion  has  followed  a  box  on  the  ear,  and 
even  simple  concussions  such  as  that  produced  by 
a  loud  report. 

The  umbo,  or  deepest  point  of  the  depression  in 
the  diaphragm,  is  just  below  the  centre  of  the  en- 
tire membrane,  and  corresponds  to  the  attachment 
of  the  end  of  the  handle  of  the  malleus.  The  rest  of 
the  handle  can  be  seen  through  the  membrane  dur- 
ing life.  The  head  of  the  malleus  is  in  no  connec- 
tion with  the  membrane,  being  situated  in  the 
attic  of  the  tympanum  above  the  level  of  the  mem- 
brane (Fig.  18).  The  segment  of  the  membrane 
above  the  umbo  is  very  freely  supplied  by  vessels 
and  nerves  ;  it  corresponds  to  the  handle  of  the 
malleus,  and  to  the  chain  of  ossicles,  and  is  oppo- 
site to  the  promontory  and  the  two  fenestrse.  The 
chorda  tympani  nerve  also  runs  across  this 
supraumbilical  portion.  The  segment  below  the 
umbo,  on  the  other  hand,  corresponds  to  no  very 
important  parts,  and  is  less  vascular  and  less  sen- 
sitive. Paracentesis  of  the  tympanum  through  the 
membrana  tympani  should  therefore  always  be  per- 
formed in  the  subumbilical  segment.  If  performed 
above  the  umbo  the  knife  may  strike  the  incus  and 


Ohap.  V]  THE   EAE  85 

loosen  that  bone  from  its  frail  attachments,  or 
the  chorda  tympani  be  cut,  which  would  give  rise 
to  a  paralytic  secretion  of  saliva.  The  malleus 
and  stapes  are  too  firmly  attached  to  be  readily 
detached. 

The  membrane  is  supplied  by  the  stylo-mastoid 
artery  and  the  tympanic  branch  of  the  internal 
maxillary,  and  obtains  its  nerve  supply  from  the 
auriculo-temporal  and  vagus. 

A/1TRUM 

Ext.5emiCIRC.Ca/sal 
Vli^flERVE 
AUDITUS 

Fenestra  Ovalis 
Tec  mem      Tympani 
Processus  Cocm. 


PrOMO/STORY     ^v^-v.  ' 

PyRAMID  Vv"-S     \ 

Fenestra  Rotunda    i  \    \ 
/Mastoid  Process 


Fig.  19. — The  inner  wall  of  tympanum  and  antrum. 

The  position  of  the  external  semicircular  canal  and  course  of  the  facial  nerve 

(vii.)  are  shown. 

The  tympanum.  —  The  width  of  the  tympanic 
cavity,  as  measured  from  its  inner  to  its  outer  wall, 
varies  from  2  to  4  mm.,  poth  to  ^th  of  an  inch.  The 
narrowest  part  is  that  between  the  umbo  of  the 
membrana  and  the  promontory.  A  fine  rod  thrust 
through  the  centre  of  the  membrana  tympani  would 
hit  the  promontory  of  the  inner  wall  of  the  cavity. 
Above  the  promontory  is  the  fenestra  ovalis,  and 
below  and  behind  it  the  fenestra  rotunda  (Fig.  19). 
Skirting  the  upper  and  posterior  margin  of  the 
inner  wall  of  the  tympanum  is  the  aqueduct  of 


86  SURGICAL   APPLIED    ANATOMY       [Part  I 

Fallopius,  containing  the  facial  nerve.  The  wall  of 
the  aqueduct  is  so  thin  that  inflammatory  mischief 
can  readily  extend  from  the  middle  ear  to  the  facial 
nerve.  The  upper  wall  is  very  thin,  and  but  little 
bone  separates  it  from  the  cranial  cavitv.  The 
suture  between  the  squamous  and  petrous  bones  is 
found  in  this  wall,  and  by  means  of  the  sutural 
membrane  that  separates  the  bones  in  the  young, 
inflammatory  changes  may  readily  spread  from  the 


CJA/^  EATAL  Tai  A/MQ  LE- 
UPRAMEATAL  SPme 


Facial  /Iebve 


Fig.  20. — Showing  the  position  and  relationships  of  the  various  parts  of 
the  middle  ear.     (See  also  Fig.  3,  p.  12.) 

tympanum  to  the  meninges.  The  petro-squamous 
suture  unites  at  the  end  of  the  first  year  and  usually 
contains  the  petro-squamous  vein,  a  remnant  of 
the  primitive  jugular.  The  floor  is  very  narrow.  Its 
lowest  part  is  below  the  level  of  both  the  mem- 
brana  tympani  and  the  orifice  of  the  Eustachian 
tube,  and  hence  pus  may  readily  collect  in  this 
locality  (Fig.  20).  It  is  separated  by  a  thin  piece 
of  bone  from  the  internal  jugular  vein  behind,  and 
from  the  internal  carotid  artery  in  front.  Fatal 
haemorrhage  from  the  latter  vessel  has  occurred  in 


Chap.  V]  THE   EAE  87 

connection  with  destructive  changes  in  this  part  of 
the  ear.  The  posterior-  wall  in  its  upper  part  pre- 
sents the  opening  or  auditus  of  the  antrum  of  the 
mastoid.  The  antrum  opens  into  the  attic — that 
part  of  the  tympanic  cavity  which  is  situated  above 
the  level  of  the  membrana  tympani  (Fig.  20). 

The  antrum  of  the  mastoid  (Figs.  19, 
20)  lies  above  and  behind  the  external  auditory 
meatus.  Implication  of  this  space  and  of  the  mas- 
toidal cells,  which  open  into  it  and  surround  it, 
forms  one  of  the  most  serious  complications  of 
middle  ear  disease.  It  is  large  enough  to  contain 
a  small  bean,  and  is  present  at  birth  (Fig.  21),  being 
developed  with  the  cavity  of  the  tympanum.  It  is 
closely  surrounded  by  important  structures.  Its 
roof,  formed  by  the  tegmen  tympani,  a  plate  of 
bone  only  2  mm.  thick,  separates  it  from  the  third 
temporal  convolution.  Small  veins  perforate  the 
roof  to  join  the  petro-squamous  vein,  in  the  rem- 
nant of  the  suture  of  the  same  name.  In  the  infant 
the  communication  is  even  more  free,  for  this 
suture  does  not  close  until  the  end  of  the  first  year. 
The  facial  nerve  passes  downwards  on  its  inner 
wall,  where  the  antrum  opens  into  the  attic,  and 
behind  the  facial  nerve,  also  on  the  inner  wall,  is 
the  external  semicircular  canal  (Fig.  19).  Facial 
paralysis  or  giddiness  may  follow  operations  on  the 
antrum  if  the  inner  wall  is  injured.  The  superior 
and  posterior  borders  of  the  meatus  indicate  the 
position  of  the  facial  nerve  (Fig.  20) ;  on  the  inner 
wall  of  the  antrum,  the  nerve  is  situated  14  to  22 
mm.  deep  to  the  suprameatal  triangle  (Joyce). 
The  antrum  is  separated  behind  from  the  lateral 
sinus  and  cerebellum  by  a  plate  of  bone  which 
varies  in  thickness  from  3  mm.  to  6  mm.  The 
temporo-sphenoidal  lobe,  the  lateral  sinus,  and 
the  cerebellum  are  the  common  seats  of  secondary 
infection  in  cases  of  middle  ear  disease.  At  the 
mouth  of  the  antrum  and  in  the  attic  of  the  tym- 
panum are  situated  the  incus,  the  head  of  the 
malleus  and  their  ligaments,  structures  which 
may  be  diseased  and  require  removal. 


88 


SUEGICAL   APPLIED    ANATOMY       [Part  I 


At  birth  the  outer  wall  of  the  antrum  is  formed 
by  the  postmeatal  process  of  the  squamosal,  a 
plate  of  bone  2  mm.  thick  (Fig.  21).  In  the  child  the 
antrum  is  comparatively  superficial,  and  pus  may 
easily  escape  or  be  evacuated.  The  suture  between 
the  postmeatal  part  of  the  squamosal  and  the 
petro-mastoid  disappears  in  the  second  year  of  life 
and  so  shuts  off  a  possible  route  that  pus  may  take 
to  reach  the  surface  (Fig.  21).  The  outer  wall  of 
the   antrum   steadily  increases  in   thickness   until 

Squamosal 
Antrum 
Attic 


Post. I/nf.  Fontanelle 


A/it   Imp.  Fo^tamelle 


Squamo/Iastoi 

5UTURE 

/iASToiD/  T'TyAiPA/HicRinc; 

Drum 
stylomastoid  forame/h 

Fig.  21. — The  temporal  bone  at  birth. 

The  position  of  the  antrum  and  attic  is  indicated.    The  squamo-niastoid  suture  is 
open  and  the  mastoid  process  undeveloped. 


adult  life,  when  the  depth  of  the  cavity  from  the 
surface  of  the  bone  is  found  to  vary  in  different  in- 
dividuals from  12  to  22  mm.,  about  16  mm.  being 
its  average  depth.  A  shallow  triangle  {see  Fig.  20) 
above  and  behind  the  meatus  lies  directly  over  the 
antrum  and  serves  as  a  guide  to  its  position.  It 
may  also  be  reached  by  following  the  junction  of 
the  posterior  wall  and  roof  of  the  external  auditory 
meatus.  The  drill  is  entered  5  mm.  behind  the 
meatus  and  on  a  level  with  its  upper  margin.  Its 
roof  lies  5  mm.  above  the  level  of  the  meatus.  The 
posterior  auricular  artery  passes  upwards  behind 


Ohap.  V]  THE    EAR  89 

the  meatus,  beneath  the  concha  of  the  auricle,  and 
lies  within  the  field  of  any  operation  on  the  middle 
ear. 

The  mastoid  cells  develop  with  the  growth  of 
the  mastoid  process,  which  appears  as  a  definitely 
marked  structure  in  the  second  year.  Besides  the 
antrum  there  are  also  some  cells  present  even  at 
birth  (Young).  Three  varieties  of  the  mastoid  pro- 
cess are  recognised,  each  of  which  is  about  equally 
common  :  (1)  those  in  which  the  cells  are  large  and 
communicate  with  each  other  and  with  the  antrum, 
(2)  those  in  which  the  central  cells  are  large  and 
communicate  with  the  antrum,  while  the  peripheral 
are  small  and  closed,  (3)  those  in  which  all  the 
spaces  are  small  and  closed.  The  cells  surround 
the  antrum,  and  may  pass  backwards  to  the  masto- 
occipital  suture,  forwards  to  the  suprameatal 
region,  upwards  to  the  masto-parietal  suture,  and 
downwards  to  the  apex  of  the  mastoid.  Inflamma- 
tory conditions  may  lead  to  a  thickening  of  the 
walls  of  the  mastoidal  cells,  and  the  bone  may  be- 
come so  dense  as  almost  to  resist  the  chisel.  Veins 
drain  into  the  periosteum  of  the  mastoid  from  the 
more  superficial  cells,  and  by  these  inflammation 
may  reach  the  surface  and  give  rise  to  oedema  and 
swelling  behind  the  ear. 

In  cases  where  the  outer  surface  of  the  mastoid 
has  been  spontaneously  perforated,  a  tumour,  con- 
taining air,  has  appeared  on  the  skull,  and  could 
be  increased  in  size  by  forcing  air  into  the  ear 
through  the  Eustachian  tube.  Such  tumours  are 
known  as  pneumatoceles,  and  the  process  that 
leads  originally  to  the  perforation  of  the  bone  is  of 
obscure  nature.  In  some  cases  it  seems  to  have 
been  simply  atrophic,  and  in  other  instances  to 
have  been  due  to  "caries  sicca." 

On  the  anterior  wall  of  the  tympanum  is  the 
opening  of  the  Eustachian  tube  (Figs.  18  and  19). 
This  tube  is  If  inch  long,  and  by  opening  into  the 
pharynx  serves  to  keep  a  proper  supply  of  air  in 
the  tympanum,  and  so  equalise  the  pressure  upon 
•the  two  sides  of  the  membrane.     The  floor  of  the 


90  SURGICAL   APPLIED    ANATOMY       [Part  I 

tympanum  is  below  the  level  of  the  outer  opening  of 
the  Eustachian  tube.  The  line  of  direction  of  the 
tube  lies  almost  exactly  midway  between  the  trans- 
verse and  antero-posterior  axes  of  the  base  of  the 
skull.  In  the  adult  it  inclines  downwards,  so  as  to 
form  an  angle  of  40°  with  the  horizontal.  In  the 
child  this  angle  is  only  10°  (Symington).  In  adults 
fths  of  the  tube  is  cartilaginous  and  Jth  bony 
(Symington).  On  the  outer  side  of  the  tube  lie  the 
tensor  palati,  the  third  division  of  the  fifth  nerve, 
and  the  middle  meningeal  artery.  On  the  inner 
side  are  the  retropharyngeal  tissue  and  (quite  pos- 
teriorly) the  internal  carotid  artery.  The  pharyn- 
geal orifice  of  the  tube  is  usually  shut.  During 
swallowing,  however,  it  is  opened  by  the  action 
mainly  of  the  tensor  palati  muscle.  If  the  nose  and 
mouth  be  closed  and  the  cheeks  blown  out,  a  sense 
of  pressure  is  produced  in  both  ears.  The  hearing, 
at  the  same  time,  is  dulled,  and  the  change  is  due 
to  the  bulging  out  of  the  membrana  tympani  by  the 
air  thus  forced  into  the  tympanum.  •  This  method 
of  inflating  the  middle  ear  is  known  as  Valsalva's 
method. 

In  "Politzer's  method"  of  passing  air  into  the 
Eustachian  tube,  the  patient's  mouth  is  closed, 
while  into  one  nostril  the  nozzle  of  a  caoutchouc 
bag  filled  with  air  is  introduced,  and  the  nostrils 
are  then  held  firmly  closed.  The  patient  is  asked  to 
swallow  a  mouthful  of  water,  while  at  the  same 
moment  the  bag  is  forcibly  emptied,  and  the  air, 
having  no  other  means  for  escape,  is  thus  driven 
into  the  open  Eustachian  tube.  The  surgeon  listens 
for  the  little  noise  caused  by  the  entrance  of  the 
air  by  means  of  a  tube  that  passes  between  the 
patient's  meatus  and  his  own.  Prolonged  closure 
of  the  Eustachian  tube  leads  to  deafness,  and  thus 
impairment  of  hearing  may  follow  upon  great 
thickening  of  the  mucous  membrane  of  the  tube  due 
to  the  extension  of  inflammatory  mischief  from  the 
pharynx.  In  the  deafness  associated  with  enlarged 
tonsils  and  postnasal  growths,  the  hypertrophic 
change  extends  to  the  mucous  lining  of  the  tube, 


Chap.  V]  THE   EAR  91 

and  in  the  cases  of  many  pharyngeal  growths  and 
nasal  polypi,  the  orifice  of  the  tube  is  mechanically 
obstructed.  The  near  relation  of  the  pharyngeal 
end  of  the  tube  to  the  posterior  nares  serves  to 
explain  a  case  where  suppuration  in  the  mastoid 
cells  followed  upon  plugging  of  the  nares  for 
epistaxis.  Infection  may  be  carried  up  to  the 
middle  ear  by  means  of  the  ciliated  lining  of  the 
Eustachian  tube;  C.  J.  Bond  found  that  indigo 
particles,  which  had  been  blown  within  the  naso- 
pharynx, in  a  case  of  perforation  of  the  drum,  ap- 
peared afterwards  in  a  discharge  from  the  external 
meatus. 

The  upper  edge  of  the  pharyngeal  orifice  of  the 
tube  is  about  \  an  inch  below  the  basilar  process, 
\  an  inch  in  front  of  the  posterior  wall  of  the 
pharynx,  \  an  inch  behind  the  posterior  end  of 
the  inferior  turbinate  bone,  and  \  an  inch  above 
the  soft  palate  (Tillaux).  In  the  foetus  the  orifice 
is  below  the  hard  palate;  at  birth  on  the  same 
level.  The  form  of  the  opening  is  that  of  a 
triangle.  The  opening  of  the  tube  is  effected  by 
the  tensor  palati,  levator  palati,  and  salpingo- 
pharyngeus. 

Just  behind  the  elevation  formed  at  the  orifice 
of  the  Eustachian  tube  there  is  a  depression  in  the 
wall  of  the  pharynx,  the  lateral  recess  or  fossa 
of  Rosenmuller  (Fig.  22,  p.  101).  It  may  be  mis- 
taken for  the  orifice  of  the  tube,  and  may  readily 
engage  the  point  of  a  Eustachian  catheter.  In 
cases  in  which  the  pharyngeal  tonsil  (Luscha's 
tonsil)  is  enlarged,  this  fossa  on  either  side  may 
be  greatly  deepened  and  made  to  form  a  narrow 
diverticulum.  {See  p.  153.)  To^  pass  the  Eus- 
tachian catheter,  the  instrument  is  carried  along 
the  floor  of  the  nares  with  its  concavity  down- 
wards, "  until  its  point  can  be  felt  to  drop  over 
the  posterior  edge  of  the  hard  palate  into  the 
pharynx.  The  instrument  should  now  be  with- 
drawn until  its  point  can  be  felt  to  rise  again  on 
the  posterior  edge  of  the  hard  palate ;  having 
arrived    at    this    point,    the    catheter    should    be 


92  SUEGICAL   APPLIED    ANATOMY       [Part  1 

pushed  onwards  about  1  inch,  and  during  its 
passage  its  point  should  be  rotated  outwards 
through  a  quarter  of  a  circle. ';  This  manoeuvre 
should  engage  it  on  the  orifice  of  the  tube. 

Blood  supply.— The  tympanum  is  supplied  by 
the  following  arteries  :  The  tympanic  of  the  in- 
ternal maxillary  and  internal  carotid,  the  petro- 
sal of  the  middle  meningeal,  and  the  stylo-mastoid 
of  the  posterior  auricular.  The  fact  that  some  of 
the  tympanic  veins  end  in  the  superior  petrosal 
and  lateral  sinuses  gives  another  explanation  of 
the  frequent  occurrence  of  thromboses  of  those 
channels  in  inflammatory  affections  of  the  middle 
ear.  The  petro-squamous  vein,  which  crosses  the 
roof  of  the  middle  ear,  also  receives  branches 
from  the  antrum  and  attic  and  joins  the  lateral 
sinus  behind  and  the  meningeal  veins  in  front 
(Cheatle). 

The  lymphatics  of  the  middle  ear  follow  two 
routes.  The  majority  pass  along  the  wall  of  the 
Eustachian  tube  and  end  in  the  retropharyngeal 
lymphatic  gland.  Others  reach  the  postauricular 
group  of  glands,  situated  over  the  mastoid  process, 
by  passing  out  beneath  the  lining  membrane  of 
the  meatus  and  by  other  efferent  channels  which 
accompany  the  veins  escaping  by  the  superficial 
openings  seen  on  the  mastoid  part  of  the  temporal. 

The  chorda  tympani  nerve,  from  its  exposed 
position  in  the  tympanum,  is  very  likely  to  be 
damaged  in  suppurative  disease  of  the  middle 
ear ;  and  Urbantschitsch  and  Schulte  have  shown 
that  such  disease  in  this  part  may  be  associated 
with  anomalies  of  taste. 

The  osseous  labyrinth  is  formed  independ- 
ently of  the  other  bony  parts  of  the  ear.  Portions 
of  this  labyrinth  have  necrosed  and  have  been 
expelled  in  recognisable  fragments.  In  a  case 
recorded  by  Dr.  Barr  the  whole  of  the  osseous 
labyrinth  (the  cochlea,  vestibule,  and  semicircular 
canals)  was  removed  entire  as  a  necrosed  frag- 
ment from  the  auditory  meatus.  Suppuration  of 
the  middle  ear  may  spread  to  the  inner  ear,  either 


Chap.  V]  THE    EAR  93 

through  the  fenestra  ovalis,  in  which  the  foot 
plate  of  the  stapes  is  fixed  by  the  strong  annular 
membrane,  or  by  the  fenestra  rotunda,  which  is 
closed  by  the  membrana  secundaria.  From  the 
inner  ear  the  suppurative  process  may  extend  in- 
wards along  the  auditory  nerve  and  meatus,  thus 
reaching  the  large  subarachnoid  spaces  at  the  base 
of  the  brain. 


CHAPTER    VI. 

THE   NOSE   AND   NASAL    CAVITIES 

1.  The  nose.  —  The  skin  over  the  root,  and  the 
greater  part  of  the  dorsum,  of  the  nose,  is  thin 
and  lax.  Over  the  alse,  however,  it  is  thick,  very 
adherent  to  the  deeper  parts,  and  plentifully 
supplied  with  sebaceous  and  sweat  glands.  In- 
flammation of  the  integuments  over  the  cartilagin- 
ous portion  of  the  nose  is  apt  to  be  very  painful, 
and  to  be  associated  with  much  vascular  engorge- 
ment. The  pain  depends  upon  the  tenseness  of  the 
part,  which  prevents  it  from  swelling  without  pro- 
ducing much  pressure  upon  the  nerves,  while  the 
engorgement  depends  upon  the  free  blood  supply 
of  the  region,  and  the  fact  that  the  edge  of  the 
nostril  being  a  free  border,  the  circulation  there 
is  terminal,  and  apt  therefore  to  favour  con- 
gestion. 

The  great  number  of  sebaceous  glands  about 
the  lower  part  of  the  nose  renders  it  a  favourite 
spot  for  acne.  It  is  here  that  the  form  of  acne 
termed  acne  hypertrophica  is  met  with,  a  con- 
dition that  produces  the  appearance  known  as 
"  grog  blossoms."  The  nose,  too,  is  frequently 
attacked  by  lupus,  and  it  is  indeed  over  the 
dorsum  of  the  nose  that  lupus  erythematosus  is 
most  commonly  met  with.  Rodent  ulcer  also  is 
apt  to  appear  in  this  region,  especially  in  the 
fold  between  the  ala  of  the  nose  and  the  cheek. 

The  integument  of  the  nose  is  very  well  sup- 
plied with  blood,  and  for  this  reason  the  part  is 

n 


Chap.  VI]     NOSE   AND    NASAL    CAVITIES  95 

well  suited  for  the  many  plastic  operations  that 
are  performed  upon  it.  Wounds  in  this  region 
heal  kindly,  and  even  the  extensive  wound  made 
along  the  line  between  the  nose  and  the  cheek  in 
removal  of  the  upper  jaw  leaves  very  little  de- 
formity. In  many  reported  cases  portions  of  the 
nose  have  been  entirely  severed,  and  have  united 
to  the   face  on  being   immediately   re-applied. 

The  skin  over  the  root  of  the  nose  is  supplied 
by  the  nasal  branch  of  the  first  division  of  the 
fifth;  as  is  also  the  skin  over  the  alse  and  in 
the  region  of  the  nostril  (Fig.  4,  p.  15).  The 
greater  part  of  the  side  of  the  nose  is  supplied  by 
the  second  division  of  the  fifth,  and  is  the  seat  of 
pain  in  neuralgia  of  that  trunk.  The  fact  that 
the  nasal  nerve  is  a  branch  of  the  ophthalmic 
trunk,  and  has  intimate  connections  with  the  eye, 
serves  to  explain  the  lachrymation  that  often 
follows  painful  affections  about  the  nostril,  as, 
for  example,  when  the  edge  of  the  nostril  is 
pinched. 

The  cartilaginous  part  of  the  nose  is  often 
destroyed  by  lupus,  by  syphilitic  ulceration,  and 
other  destructive  affections.  The  parts  so  lost 
have  been  replaced  by  the  various  methods  in- 
cluded under  the  head  of  rhinoplasty.  It  is  well 
to  bear  in  mind  the  limits  of  the  cartilaginous 
segment  of  the  nose,  and  to  remember  that  in  in- 
troducing a  dilating  speculum  the  instrument 
should  not  be  passed  beyond  those  limits.  In  the 
subjects  of  inherited  syphilis  the  bridge  of  the, 
nose  is  often  found  to  be  greatlv  depressed  This 
depends  upon  no  actual  loss  of  parts,  but  rather 
upon  imperfect  development  from  local  mal- 
nutrition, that  malnutrition  following  upon  a 
severe  catarrh  of  the  mucous  membrane.  The  de- 
formity only  occurs,  therefore,  in  those  who  have 
had  "  snuffles  "  in  infancy. 

The  nasal  bones  are  oftsn  broken  by  direct 
violence.  The  fracture  is  most  common  through 
the  lower  third  of  the  bones,  where  they  are  thin- 
nest   and    least    supported.     It    is    rarest    in    the 


96  SURGICAL   APPLIED    ANATOMY       [Part  I 

upper  third,  where  the  bones  are  thick  and  firmly 
held,  and  where,  indeed,  considerable  force  is 
required  to  produce  a  fracture.  Since  no  muscles 
act  upon  the  ossa  nasi,  any  displacement  that 
occurs  is  due  solely  to  the  direction  of  the  force. 
Union  takes  place  after  these  fractures  with 
greater  rapidity  than  perhaps  obtains  after  frac- 
ture of  any  other  bone  in  the  body.  In  one  case 
Vioted  by  Hamilton,  "  the  fragments  were  quite 
firmly  united  on  the  seventh  day."  If  the  mucous 
membrane  of  the  nose  be  torn,  these  fractures  are 
a,pt  to  be  associated  with^  emphysema  of  the  sub- 
cutaneous tissue,  which  is  greatly  increased  on 
blowing  the  nose.  The  air  in  such  cases  is  de- 
rived, of  course,  from  the  nasal  fossae.  In  frac- 
tures of  the  upper  third  of  the  ossa  nasi  the 
cribriform  plate  may  be  broken,  but  it  is  ques- 
tionable whether  this  complication  can  occur 
when  the  fracture  is  limited  to  the  lower  third 
of  the  bones.  The  root  of  thp  nnsft  is  a,  favourite 
'pla.ce  for  meningoceles  and  encephalnr.pl ps,  thp. 
protrusion  escaping  through  the  sutures  between 
the  nasal  and  frontal  bones.  Such  protrusions^ 
when  occurring  in  this  place,  are  often  covered 
by  a  thin  and  vascular  integument,  and  have  been 
mistaken  for  nsevoid  growths. 

2.  The  nasal  cavities.— The  anterior  nares 
have  somewhat  the  shape  of  the  heart  on  a  play- 
ing card,  and  the  aperture  as  a  whole  measures 
about..  1|  inches  vertically,  and  a  little  less  than 
Lj  inches  transversely,  at  its  widest  part.  The 
plane  of  the  nostril  is  a  little  below  that  of  the 
floor  of  the  nares.  To  examine  the  nasal  cavities, 
therefore,  the  head  should  be  thrown  back,  and 
the  nose  drawn  upwards.  The  anterior  nares  can 
be  well  explored  by  the  finger  introduced  into  the 
nostril,  and  the  nasal  apertures  are  just  so  wide 
on  each  side  of  the  septum  as  to  allow  the  finger 
to  be  passed  far  enough  back  to  reach  another 
finger  introduced  into  the  posterior  nares  through 
the  mouth.  An  effectual  way  of  removing  soft 
polypi  in  the  adult  is  by  tearing  them  away  by 


Chap.  VI]     NOSE   AND    NASAL    CAVITIES  97 

two  fingers  so  introduced.  The  operation  is  a 
little  rough.  By  the  most  gentle  introduction  of 
the  finger  into  the  nostril  it  is  often  possible  to 
feel  the  end  of  the  inferior  turbinated  bone.  The 
anterior  nares,  and  front  of  the  nasal  cavities, 
can  be  well  explored  by  Rouge's  operation.  In 
this  procedure  the  upper  lip  is  everted,  and  a 
transverse  cut  made  through*  the  mucous  mem- 
brane into  the  soft  parts  that  connect  the  upper 
lip  with  the  upper  jaw.  The  incision  extends  be- 
tween the  second  bicuspid  teeth  of  either  side. 
The  soft  parts  connecting  the  upper  lip  and  nose 
to  the  bone  are  divided  without  damaging  the* 
skin,  and  the  flap  is  dissected  up  until  the  nares 
are  sufficiently  exposed. 

The  posterior  nares. — If  a  little  mirror, 
somewhat  similar  to  that  used  in  laryngoscopy, 
be  cautiously  introduced  behind  the  soft  palate 
through  the  mouth,  and  illumined  from  the  mouth 
the  following  parts  may,  under  favourable  cir 
cumstances,  be  seen  :  the  posterior  nares,  the  sep- 
tum, the  middle  turbinated  bone,  part  of  the 
superior  and  inferior  turbinated  bones,  and  pari 
of  the  inferior  meatus.  The  middle  meatus  is  well 
seen,  and  also  the  Eustachian  tube,  and  the 
mucous  membrane  of  the  upper  part  of  the 
pharynx. 

This  mode  of  examination  is  very  riiffinii]f.  fro 
carfyout,  and  is  known  as  poster  i  or  rhinoscopy 
The  parts  just  named  can  all  be  felt  by  the  finger 
introduced  behind  the  soft  palate  through  the 
mouth.  The  posterior  nares  are  often  plugged  to 
arrest  severe  bleeding  from  the  nose,  and  in  order 
to  cut  a  proper  sized  plug  it  is  desirable  to  bear 
in  mind  the  dimensions  of  the  apertures.  Each 
aperture  is  of  regular  shape,  and  measures  about 
ij  an  inch  transversely  by  1^  inch  in  the  vertical 
direction  in  a  well-developed  adult  skull. 

As  regards  the  nasal  cavities  generally,  it  is 
well  to  note  that  the  floor  is  wider  at  the  centre 
than  at  either  end,  that  the  vertical  diameter  is 
greater  than  the  transverse,   and  is  also  greatest 

H 


98  SURGICAL    APPLIED    ANATOMY       [Part  1 

about  the  centre  of  the  fossae.  Forceps  introduced 
into  the  nose,  therefore,  are  most  conveniently 
opened  if  opened  vertically.  The  width  of  the 
fossae  increases  somewhat  from  above  downwards ; 
thus  the  superior  turbinated  bone  is  only  2  mm. 
from  the  septum,  while  a  space  of  from  4  to 
5  mm.  intervenes  between  the  inferior  turbinated 
bone  and  the  septum.  _  The  nasal  cavity  is  so  very 
narrow  above  the  middle  turbinated  bone  that 
that  bone  really  forms  the  surgical  roof  of  the 
nasal  fossae. 

The  shape  and  proportions  of  the  nasal 
cavity  in  the  child  are  peculiar.  In  the  adult 
the  inferior  meatus  is  large,  and  constitutes  the 
chief  respiratory  passage;  in  the  young  child 
the  inferior  meatus  is  relatively^  very  small,  the 
middle  meatus  affording  the  main  space^  for  the 
respiratory  tide  (Lack).  The  nasal  cavities  grow 
rapidly  from  the  sixth  to  the  eighteenth  year ; 
during  this  period  the  permanent  dentition  is  be- 
ing formed,  necessarily  causing  an  increase  in  the 
size  of  the  palate  and  of  the  floor  of  the  nose ;  at 
the  same  time  the  development  of  the  antrum  of  the 
maxilla  leads  to  an  increase  in  the  vertical  height 
of  the  nose,  this  increase  affecting  the  lower  or 
maxillary  much  more  than  the  ethmoidal  or  olfac- 
tory part  of  the  cavity.  Growth  of  the  nasal 
rajntips  a.nrl  of  thp  fa,f»Pi  ma.v  hp  Trrastp.d  or  viti- 
ated bv  any  obstruction  to  thp.  fr^p  p?gggga  "f  +ha 
hrpath  through  thp.  nosp. ;  thp.  most  r.omrnon  r.a.-nsp 
Qf-obstruGtion  is  the  formation  of  jaxlgnoids  in  \hf 
naao-pharynx. 

From  a  reference  to  the  relations  of  the  nasal 
fossae  (Fig.  22)  it  will  be  understood  that  inflam- 
mation of  the  lining  membrane  (coryza)  may  ex- 
tend to  the  pharynx  vid^  the  posterior  nares ;  may 
extend  up  the  Eustachian  tube  and  cause  some 
deafness ;  may  reach  the  lachrymal  sac  and  con- 
junctiva  through  the  nasal  duct;  and  may  extend 
to  the  frontal  sinuses  and  the  antrum,  producing 
frontal  headache  and  cheekache.  These  relation- 
ships are   often   demonstrated  in   a  severe   "  cold 


Chap.  VI]     NOSE   AND    NASAL    CAVITIES  99 

in  the  head."  From  the  nearness  of  the  nasal 
fossae  to  the  cranial  cavity  it  happens  that  menin- 
gitis has  followed  upon  purulent  inflammations  of 
the  nose.  Foreign  bodies  of  various  kinds  are 
often  lodged  in  the  nose,  and  may  remain  there 
for  some  years.  Thus  Tillaux  reports  the  case  oi 
an  old  woman,  aged  64,  from  whose  nose  he  re 
moved  a  cherry  stone  that  had  been  there  foi 
twenty  years. 

In"  washing  out  the  nasal  cavities  with  the 
44  nasal  douche "  the  fluid  is  introduced  by 
means  of  a  syphon.  The  nozzle  of  the  syphon  tube 
is  introduced  into  one  nostril,  the  mouth  is  kept 
open,  and  the  fluid  runs  through  that  nostril, 
passes  over  the  soft  palate,  and  escapes  from  the 
other  nostril.  The  latter  cavity  is  therefore 
washed  out  from  behind  forwards.  The  course  of 
the  fluid  depends  upon  the  fact  that  when  the 
mouth  is  kept  open  there  is  such  a  disposition  to 
breathe  through  it  alone  that  the  soft  palate  is 
drawn  up  and  the  nares  cut  off  from  the  pharynx. 

The  roof  of  each  nasal  fossa  is  very  narrow, 
being  only  about  ^  of  an  inch  in  width.  It  is 
mainly  formed  by  the  thin  cribriform  plate,  but 
its  width  is  such  that  the  danger  of  the  roof  being 
penetrated  by  so  large  a  substance  as  a  pair  of 
polyp  forceps  has  been  greatly  exaggerated.  The 
cranial  cavity  has,  however,  been  opened  up 
through  the  roof  of  the  nose  by  penetrating  bodies 
introduced  both  by  accident  and  with  homicidal 
intent.     Meningitis  has  followed  inflammation  nf 

the     nasal     fosg^    the — inflammation extending 

through  the  cribriform  plate.  Through  the  peri- 
neural   and   perivascular    sheaths   the  ^  lymphatic 

sy stern"  of    the    nose    is    in    rrmtinnity    with    that   ni 

the  meninges,  and  by  these  channels  infections 
may  spread  from  the  roof  of  the  nose  to  the  mem- 
branes of  the  brain.  Fracture  of  this  part  also 
has  been  associated  with  very  copious  escape  of 
cerebro-spinal  fluid  through  the  nostrils.  A  men- 
ingocele may  protrude  through  the  nasal  roof. 
In  a  case  reported  by  Lichtenberg  the  mass  hung 


100  SURGICAL    APPLIED    ANATOMY       [Part  I 

from  the  mouth,  having  passed  through  a  congeni- 
tal fissure  in  the  palate.  It  was  mistaken  for  a 
polyp,  was  ligatured,  and  death  resulted  from 
intracranial  inflammation. 

The_    sgptmii      is     seldom quite — straight     in 

adults;    the    deviation    hmng    more    nft.pn    inwards 

the  left.  It  is,  however,  straight  in  children, 
and  remains  so  up  to  the  seventh  year.  In  adults 
the  septum  deviates  in  76  per  cent,  of  all  persons. 
The  deviation  may  follow  an  injury.  It  has  been 
pointed  out  that  a  deviation  of  the  septum  may 
seriously  interfere  with  the  singing  voice.  The 
nose  also  is  seldom  quite  straight,  and  French 
authors  ascribe  this  to  some  deviation  of  the  sep- 
tum, often  dependent  upon  the  practice  of  always 
blowing  the  nose  with  the  same  hand.  If  the 
deviation  of  the  septum  be  considerable,  it  may 
more  or  less  block  one  nostril,  and,  until  the  oppo- 
site nostril  is  examined,  be  mistaken  for  a  septal 
tumour  encroaching  upon  the  cavity.  The  flat- 
tened nose  in  acquired  syphilis  is  usually  due 
to  destruction  of  the  septum  and  more  or  less 
implication  of  the  adjacent  bones.  Workmen  ex- 
posed to  the  vapour  of  bichromate  of  potash  are 
liable  to  a  peculiar  perforation  of  the  septum 
known  as  "  bichromate  disease." 

Outer  wall  (Fig.  22). — The  inferior  turbin- 
ated bone  may  interfere  with  the  introduction  of 
a  Eustachian  catheter  if  the  curve  of  the  instru- 
ment be  too  great.  The  anterior  end  of  the  bone 
is  about  |  of  an  inch  behind  the  orifice  of  the 
nostril.  The  opening  of  the  nasal  duct  is  about 
1  inch  behind  the  orifice  of  the  nostril,  and  about 
|  of  an  inch  above  the  nasal  floor.  This  opening 
is  usually  slit-like  and  narrow.  The  nasal  duct 
pierces  the  nasal  mucous  membrane  in  the  same 
oblique  and  valvular  manner  as  the  ureter  enters 
the  bladder.  The  height  of  the  inferior  meatus  is 
about  |  of  an  inch.  The  superior  meatus  is  a 
very  short  and  narrow  fissure,  and  into  its  upper 
and  fore  part  open  the  posterior  ethmoidal  cells. 
The  middle  meatus  opens  widely  in  front  upon  a 


Chap.  VI]     NOSE   AND    NASAL    CAVITIES 


101 


part  of  the  outer  wall  called  the  atrium,  and 
unless  care  be  taken  to  keep  the  point  of  any  in- 
strument well  towards  the  floor  of  the  fossa,  it 
is  easier  to  pass  the  instrument  into  the  middle 
than  into  the  inferior  meatus.  Upon  the  wall  of 
the  middle  meatus  is  a  deep  gutter  (the  hiatus 
semilunaris),  which  runs  from  above  downwards 
and  backwards  (Fig.  22).     Into  this  groove  open 


aey  Fossa 
oidal  Sinus 


ey/scEAL  Tonsil 

Lateral  Recess 

Eustachian  Tube 
Eustachian  Cus/iion 
Atlas 


Soft  Palate 


Fig.  22. — The  outer  wall  of  the  nasal  cavity. 

Tne  greater  part  of  the  middle  turbinate  process  lias  been  cut  away  to  expose  the 
hiatus,  bulla  and  openings,  a,  b,  indicate  the  two  positions  at  which  the 
opening  of  the  antrum  may  occur. 

the  infundibulum  (the  aperture  of  the  frontal 
sinus),  the  anterior  ethmoidal  cells,  and,  near  its 
posterior  end,  the  antrum.  The  rounded  aperture 
of  the  frontal  sinus  is  usually  situated  in  the 
anterior  end  of  the  hiatus,  but  not  unfrequently 
it  will  be  found  in  a  recess  above  and  in  front  of 
the  hiatus.  The  anterior  ethmoidal  cells,  usually 
two  in  number,  may  open  into  the  hiatus,  the 
infundibulum,  or  directly  into  the  anterior  part 
of  the  middle  meatus.     The  opening  of  the  antrum 


102  SURGICAL    APPLIED    ANATOMY       [Part  1 

may  occur  below,  instead  of  within,  the  posterior 
part  of  the  hiatus  semilunaris  (Fig.  22).  The 
upper  boundary  of  the  hiatus  is  formed  by  the 
bulla  ethmoidalis ;  its  lower  sharp  prominent 
margin  contains  the  uncinate  process  of  the  eth- 
moid. The  middle  ethmoidal  cell  is  seen  to  open 
on  the  bulla,  above  the  hiatus  semilunaris.  .  The 
level  of  the  hiatus  within  the  nose  may  be  indi- 
cated by  the  position  of  the  internal  tarsal  liga- 
ment. The  anterior  end  or  beak  of  the  middle 
turbinate  process  can  be  seen  distinctly  from  the 
anterior  nares,  when  the  interior  of  the  nose  is 
illuminated   by   reflected   light. 

The  width  of  the  nasal  floor  is  about  ^  an 
inch,  or  a  little  over.  Its  smooth  surface  greatly 
favours  the  passage  of  instruments.  It  presents 
a  gentle  slope  from  before  backwards.  At  its 
anterior  part  is  a  depression  of  mucous  membrane 
over  the  incisor  foramen.  This  foramen  is  a 
vestige  of  the  great  communication  that  once 
existed  between  the  cavities  of  the  nose  and  mouth. 

The  mucous  membrane  lining  the  nasal  cavi- 
ties is  covered  by  ciliated  epithelium  over  the 
lower  two-thirds  or  respiratory  part;  the  upper- 
third — the  olfactory  part — is  covered  by  columnar 
epithelium,  while  the  vestibule  is  lined  by  strati- 
fied epithelium-  It  is  very  thick  and  vascular 
over  the  turbinate  bones  and  over  the  lower 
two-thirds  of  the  septum,  while  over  the  nasal 
floor  and  in  the  intervals  between  the  turbinate 
bones  it  is  very  much  thinner.  The  mucous 
membrane  lining  the  various  sinuses  and  the 
antrum  is  conspicuously  thin  and  pale.  The 
membrane  is  provided  with  many  glands,  which 
are  most  conspicuous  over  the  lower  and  hinder 
parts  of  the  outer  wall  and  over  the  posterior 
and  inferior  parts  of  the  septum.  These  glands 
may  be  the  subject  of  considerable  hypertrophy. 
They  are  capable  of  providing  also  a  very  copious 
watery  secretion,  which  has  in  some  cases  of 
chronic  coryza  following  injury  been  so  free  as 
to   be    mistaken    for   an   escape   of   cerebro-spinal 


Chap.  VI]    NOSE   ANt)    NASAL    CAVITIES  103 

fluid.  There  is  also  much  adenoid,  or  lym- 
phoid, tissue  in  the  nasal  mucous  membrane, 
which  is  the  primary  seat  of  the  chief  scrofulous 
affections  thaj|invade  this  part.     Sn  think  and  lax 

JS    f^    T"invTTJTy  niUCOUS    Tnpr"hrnnp    ovpt    thi?    Inwpr 

border  and  posterior  extremity  of  the  inferior 
turbinnted    bones    that   it   forms    a   kind    of    soft 

p_TT3hinnJ    gnmptjrnpg    na.Ued    thp    "  fvnrbina tphodv. ' ' 

This  condition  is  mainly  due  to  the  presence  of  a 
rich  submucous  venous  plexus,  the  vessels  of  which 
run,  for  the  most  part,  in  an  antero-posterior 
direction.  "When  turgid  with  blood  it  swells  so 
as  to  obliterate  the  interval  between  the  bone  and 
the  septum.  When  the  seat  of  chronic  inflam- 
mation, the  mucous  membrane  over  the  inferior! 
bone  may  appear  as  a  polypoid  swelling. 

Polypi  are  often  met  with  in  the  nose.  They 
are  of  two  kinds,  the  mucnus  or  myxoTngfniiq 
polyp  that  springs  usually  from  the  mucous  mem- 
brane beneath  or  over  the  middle  turbinate,  and 
thp  fibrous  or  Karnornafniis — polyp  that  usually 
takes  origin  from  the  periosteum  of  the  nasal 
roof  or  from  that  of  the  base  of  the-  skull.  Polypi 
of  the  latter  kind  spread  in  every  available  direc- 
tion. They  expand  the  bridge  of  the  nose,  close 
the  nasal  duct  and  cause  epiphora,  depress  the 
hard  palate  and  encroach  upon  the  mouth,  in- 
vade the  antrum  and  expand  the  cheek,  grow 
down  into  the  pharynx,  pushing  forwards  the 
velum  palati,  and  may  penetrate  even  through  the 
inner  wall  of  the  orbit.  Such  tumours  may  be 
exposed  and  removed  by  separating  the  posterior 
and  inner  attachments  of  the  superior  maxilla, 
turning  it  forwards,  thus  exposing  the  nasal 
cavity  by  detaching  its  outer  wall.  The  bone  may 
be  replaced  in  situ  after  removal  of  the  tumour 
(F.   S.  Eve). 

The  blood  supply  of  the  nasal  cavity  is  ex- 
tensive, and  is  derived  from  the  internal  maxil- 
lary ophthalmia,  and  facial  arteries.  With 
regard  to  the  veins,  it  may  be  noted  that  the 
^ethmoidal  veins  that  come  from  the  nose  enter  the 


104  SURGICAL    APPLIED    ANATOMY       [Part  I 

ophthalmic  vein,  while  in  children  a  constant  com- 
munication exists  between  the  nasal  veins  and  the 
superior  longitudinal  sinus  through  the  foramen 
csecum.  This  communication  mayg^Jso  be  main- 
tained in  the  adult,  These  connexions  may,  in 
part,  serve  to  explain  the  occurrence  of  intra- 
cranial mischief  as  a  consequence  of  certain  in- 
flammatory affections  of  the  nasal  cavities. 
Bleeding  from  the  nose,  or  epistaxis,  is  a  common 
and  often  a  serious  circumstance.  Its  frequency 
is  to  a  great  extent  due  to  the  vascularity  of  the 
mucous  membrane,  to  its  laxity,  and  to  the  fact 
that  the  veins,  especially  those  over  the  lowest 
turbinate  bone,  form  extensive  plexuses,  and  pro- 
duce a  kind  of  cavernous  tissue.  The  epistaxis  is 
often  due,  therefore,  to  interference  with  the 
venous  circulation,  as  seen  in  cases  of  cervical 
tumour  pressing  upon  the  great  veins,  in  the 
paroxysms  of  whooping  cough,  and  the  like.  The 
beneficial  effect  of  raising  the  arms  in  epistaxis 
is  supposed  to  depend  upon  the  extra  expansion 
of  the  thorax  thus  produced,  and  the  aspiratory 
effect  thus  brought  to  bear  upon  the  cervical  veins. 
The  bleeding  may  be  copious  and  long  continued. 
Thus  Spencer  Watson  reports  a  case  where  tlie 
epistaxis  continued  on  and  off  for  twenty  months 
without  obvious  cause.  Martineau  mentions  an 
instance  in  which  12  lb.  of  blood  was  lost  in  sixty 
hours,  and  Fraenkel  records  a  case  where  75  lb. 
of  blood  is  said  to  have  escaped  from  first  to 
last.  In  several  instances  the  haemorrhage  has 
proved  fatal.  The  seat  of  the  bleeding  is  often 
not  easy  to  detect,  even  when  the  examination  is  , 
post  mortem.  In  many  cases  the  bleeding  point 
is  situated  on  the  septum,  |  an  inch  above  and 
behind  the  nasal  spine. 

The  nerve  supply  of  these  parts  is  derived 
from  the  olfactory  nerve,  and  frorn"  tjie  first  arid 
second  divisions  of  the  fifth  nerve.  The  lachryma- 
tion  that  often  follows  the  introduction  of  irri- 
tants into  the  front  of  the  nares  may  be  explained 
by  the  fact  that  that  part  of  the  cavity  is  sup- 


Chap.  VI]    NOSE   AND   NASAL    CAVITIES  105 

plied  freely  by  the  nasal  nerve,  a  branch  of  the 
ophthalmic  trunk.  As  an  example  of  transfer- 
ence of  nerve  force  in  the  opposite  direction  may 
be  noted  cases  where  a  strong  sunlight  falling 
upon  the  eyes  has  produced  an  attack  of  sneez- 
ing. Troubles  involving  the  vagal  centres,  such 
as  cough  and  bronchial  asthma,  have  followed 
affections  of  the  nasal  cavities.  The  olfactory 
nerves  are  situated  in  the  upper  third  of  the 
cavity,  and  thus,  in  smelling  intently,  the  indi- 
vidual sniffs  deeply  and  dilates  the  nostril.  The 
inability  to  dilate  the  nostril  in  facial  paralysis 
may  explain  "the  partial  loss  of  smell  sometimes 
noted  in  such  cases.  It  is  said  (Althaus)  that 
ajiosjiinsia,  or  loss  of  the  sense  of  smell,  when 
following  upon  an  injury  to  the  head,  may  be  due 
to  a  rupture  of  the  olfactory  nerve  fibres  as  they 
pass  through  the  cribriform  foramina.  The  olfac- 
tory roots  cross  the  edge  of  the  lesser  wings  of  the 
sphenoid,  and  in  falls  on  the  forehead  are  liable 
to  injury.  The  olfactory  centre  is  situated  in  the 
hippocampal  gyrus. 

Most  of  the  lymphatics  of  the  nasal  fosses 
enter  the  retropharyngeal  glands  placed  behind 
the  pharynx,  in  front  of  the  rectus  capitis  anticus 
major.  Hence,  as  Fraenkel  has  pointed  out, 
"  retropharyngeal  abscess  may  arise  in  conse- 
quence of  diseases  of  the  nose/'  Other  lympha- 
tics go  to  the  submaxillary,  parotid,  and  upper 
deep  cervical  lymph  glands,  and  it  is  common  to 
find  these  enlarged  in  nose  affections,  especially  in 
the  scrofulous.  The  lymphatics  of  the  nose  also 
communicate  with  those  of  the  meninges  through 
the  cribriform  plate. 

The  nasal  sinuses. — Of  late  years  a  know- 
ledge of  the  anatomy  and  relationships  of  the  ac- 
cessory sinuses  of  the  nose  has  become  of  the 
utmost  importance  to  the  surgeon.  Over  15  per 
cent,  of  the  subjects  examined  in  the  dissecting 
room  of  the  London  Hospital  show  disease  of  one 
or  more  of  these  sinuses ;  St.  Clair  Thomson,  quot- 
ing   from    German    statistics,    estimates   that   the 


106 


SUKGICAL    APPLIED    ANATOMY       [Part  I 


sphenoidal  sinus  is  the  seat  of  disease  in  30  per 
cent,  of  individuals — probably  an  overstatement. 
The  collective  capacity  of  the  accessory  sinuses — 
the  maxillary,  frontal,  sphenoidal,  and  ethmoidal 
— is  more  than  twice  that  of  the  nasal  cavity 
(Braune). 


Frontal  SiauS 


AIasioa 


I/sfu/ndibulum 
Lacai.Sac 

AllD.TUfcBI/IATE- 

aIasal  Duct 

ANTRUM 

1/iF- TuRBI/iAT& 


Fig.  23.— Surface  markings  of  the  frontal  and  maxillary  sinuses. 

a,  lj"  above  nasion ;  b,  on  the  supraorbital  margin,  at  the  junction  of  the  middle 
and  outer  thirds;  C,  on  the  infraorbital  margin  to  the  outer  side  of  the 
lachrymal  sac ;  d,  on  the  centre  of  the  cheek  bone  in  line  with  the  outer 
margin  of  the  orbit ;  e,  over  the  second  bicuspid  ;  r,  over  the  last  molar.  The 
points  a,  b  and  Nasion  give  the  surface  position  of  the  frontal  sinus ;  c,  n,  e 
f,  that  of  the  maxillary  sinus 

The  frontal  sinus  is  extremely  variable  in 
size  and  shape.  The  surface  markings  shown  in 
Fig.  23  indicate  the  average  development  in  the 
adult ;  the_  opening  of  its  duct  or  infnrirlihnlnm 
is  shown  in  Fig.  22.  Large  frontal  sinuses  do 
not  necessarily  imply  large  external  prominences 


Chap.  VI]     NOSE    AND    NASAL    CAVITIES  107 

over  the  glabella  and  superciliary  eminences.  One 
sinus  may  develop  at  the  expense  of  the  other,  and 
the  septum  may  be  displaced.  They  are  larger  in 
men  than  in  women.  They  are  absent  on  one  side 
in  9  per  cent,  of  cases,  and  on  both  sides  in  7  per 
cent.  (Logan  Turner).  Bonv  tumours  oftpn  grow 
from  the  interior  of  these  sinuses,  and  arp  known 
as.  pn^st^sas  It  is  obvious  that  a  depressed  frac- 
ure  may  exist  over  a  frontal  sinus  without  the 
cranial  cavity  being  damaged.  In  such  cases  the 
inspissated  contents  of  the  sinus  have  been  mis- 
taken for  brain  matter  escaping.  Since  the 
sinuses  communicate  with  the  nose,  much  emphy- 
sema may  follow  upon  fracture  of  the  sinus  wall. 
Insects  have  found  their  way  into  these  cavities. 
"  Centipedes  are  particularly  liable  to  be  found 
in  the  frontal  sinuses,  where  they  may  remain  for  \ 
years,  the  secretions  of  these  cavities  furnishing' 
them  with  sufficient  nourishment  "  (Fraenkel).' 
Larvae  have  also  been  found  here,  and  maggots 
that  have  developed  within  the  nose  have  managed 
to  make  their  way  to  the  frontal  sinuses. 

Trip,  frontal  sinns  is  ahspnt  in  parly  nhildhoo^. 
About  the  sixth  year  a  bud  of  mucous  membrane 
grows  out  from  the  anterior  end  of  the  hiatus,  and 
gradually  insinuates  its  growing  extremity  into 
the  diploe  of  the  frontal  bone,  separating  the 
inner  from  the  outer  osseous  table.  It  reaches  its 
full  size  about  the  twenty -fifth  year ;  the  stalk  of 
the  outgrowth  becomes  the  infundibulum;  it  leads 
from  the  posterior  part  of  the  sinus.  The  infundi- 
bulum is  |  of  an  inch  long,  and  runs  downwards 
and  slightly  backwards  to  open  at  or  near  the 
anterior  end  of  the  hiatus  semilunaris.  Along  the 
hiatus  the  secretion  of  the  frontal  sinus  may  be 
conveyed  to  the  antrum,  thus  converting  that 
cavity  into  a  cesspool  in  cases  of  chronic  suppura- 
tion of  the  frontal  sinus  (Fig.  22).  The  infundi- 
bulum is  frequently  tortuous,  and  even  after  the 
beak  of  the  middle  turbinate  process  is  removed 
it  is  not  easy  to  catheterise  from  below.  Hence  in 
cases  of  obstruction  the  frontal  sinus  is  trephined 


i08  SURGICAL    APPLIED    ANATOMY       [Part  1 

over  the  glabella,  or  at  the  superior  internal  angle 
of  the  orbit  (Tilley),  and  a  probe  passed  down- 
wards and  slightly  backwards  to  drain  the  sinus 
into  the  nose.  The  anterior  ethmoidal  cells  com- 
monly open  into  the  infundibulum,  and  hence  are 
usually  involved  in  any  disease  affecting  the 
frontal  sinus.  The  frontal  diploic  vein,  which 
joins  the  frontal  vein  at  the  supraorbital  notch, 
receives  blood  from  the  frontal  sinus.  By  this 
channel  infection  may  be  disseminated  in  the 
frontal  bone  from  disease  of  the  frontal  sinus. 

The  sphenoidal  sinus  opens  on  thp  rnn^  ^ 
the  nose  behind  the  superior  meatus ;  it  is  de- 
veioped  at  the  same  period  of  life  as  the  frontal 
sinus  (Fig.  22).  It  is  deeply  placed,  and  not  very 
accessible  for  operation  when  the  seat  of  disease. 
It  is  frequently  the  seat  of  chronic  suppuration 
set  up  by  infections  from  the  nose.  Its  anterior 
wall,  which  is  comparatively  thin,  is  situated  be- 
tween V  and  8  cm.  from  the  lower  margin  of  the 
anterior  nares.  Tilley  recommends  the  mid  point 
of  the  lower  border  of  the  middle  turbinate  as  a 
guide  to  the  opening  of  the  sphenoidal  sinus.  A 
probe^  passed  to  this  point  from  the  floor  of  the 
anterior  nares  will,  if  passed  straight  onwards, 
reach  the  opening  of  the  sinus  at  the  depth  men- 
tioned above — 7  to  8  cm. 

In  close  contact  with  the  thin  lateral  wall  of  this 
sinus  there  are  certain  extremely  important  struc- 
tures^ Besides  the  cavernous  sinus  and  internal 
carotid  artery,  the  optic  nerve  and  second  division 
of  the  fifth  nerve  are  in  the  closest  contact,  and 
may  be  affected  in  sinusitis  (Fig.  26).  On  the  roof 
is  the  pituitary  body ;  tumours  of  this  body  may 
invade  the  sinus.  Its  veins  join  the  ethmoidal. 
The  walls  of  the  sinuses  are  thin  and  easily  per- 
forated, as  the  following  case,  which  occurred  re- 
cently at  the  London  Hospital,  will  show.  A 
man  stumbled  forwards  on  his  umbrella  as  he 
left  a  public-house  in  Whitechapel,  the  point 
entering  his  face  above  the  bicuspid  teeth.  He 
walked  to  the  hospital,  and  died  three  days  after- 


Chap.  VI]     NOSE   AND    NASAL    CAVITIES  109 

wards.  The  ferrule  of  the  umbrella  was  found 
embedded  in  the  pons,  the  point  having  traversed 
the  antrum  of  Highmore  and  the  sphenoidal  sinus. 

The  antrum  exists  at  birth,  but  attains  its 
largest  dimensions  in  old  age.  The  surface  mark- 
ings  for  indicating  its  position  on  the  face  are 
given  in  Fig.  23.  The  walls  of  the  cavity  are 
thicker  in  children  than  in  adults.  Tummirs  of 
various  kinds  are  apt  tn  dp.vplop  in  this  na.yity, 
and  to  distend  its  walls  in  various  directions. 
Thus  the  growth  breaks  through  the  thin  inner 
wall  and  invades  the  nose,  it  pushes  up  the  roof 
of  the  cavity  and  invades  the  orbit,  it  encroaches 
upon  the  mouth  through  the  floor  of  the  antrum, 
and  makes  its  way  also  through  the  somewhat 
slender  anterior  wall  into  the  cheek.  The  densest 
part  of  the  antrum  wall  is  that  in  relation  to  the 
malar  bone,  and  this  part  does  not  yield.  There 
is  little  inducement  for  any  growth  to  spread 
backwards,  although  it  sometimes  invades  the 
zygomatic  and  pterygo-maxillary  fossae.  As  the 
infraorbital  nerve  runs  along  the  roof  of  the 
antrum,  while  the  nerves  of  the  upper  teeth  are 
connected  with  its  walls,  these  structures  are 
pressed  upon  in  growths  springing  from  the 
antrum,  and  thus  neuralgia  of  the  face  and  teeth 
is  often  produced.  In  tapping  the  antrum  a  spot 
is  usually  selected  "just  above  the  second  bicus- 
pid ^ tooth",  sinop  thp.  houp.  is  hp.rp  thin  and  is  con- 
veniently reached.  In  some  cases  it  is  sufficient 
to  py tract  one  of  the  molar  teeth,  since  the  fangs 
of  these  often  enter  the  cavity  of  the  antruim  The 
tooth  usually  selected  is  either  the  first  or  the 
third  molar.  Not  unfrequently  the  antrum  com- 
municates at  its  upper  anterior  part  with  the 
frontal    sinus. 

The  opening  of  the  antrum  is  shown  in  Fig.  22 ; 
it  is  on  a  level  with  the  roof  of  the  cavity ;  hence 
if  pus_  be  present  it  drains  most  freely  when  the 
head  is  turned  so  that  the  affected  chamber  is 
uppermost;  the  sphenoidal  sinus  empties  most 
easily  when  the  head  is  bent  forwards ;  the  frontal, 


110  SUKGICAL    APPLIED    ANATOMT        [Part  1 

when  the  head  is  thrown  backwards.  The  cavity 
of  the  antrum  is  small  if  the  inferior  meatus  is 
large  or  if  the  canine  fossa  of  the  face  be  well 
marked.  The  lymphatics  of  the  sinuses  drain 
into  the  retropharyngeal  glands!  As  the  result  of 
a  fall,  one  of  the  upper  teeth  has  been  entirely 
driven  into  the  antrum  and  lost  to  view.  In  one 
case,  reported  by  Haynes  Walton,  an  upper  in- 
cisor was  found  lying  loose  in  the  antrum  three 
and  a  half  years  after  the  accident  that  had 
driven  it  there. 


CHAPTER    VII  .     ... 

THE    FACE 

The  parts  of  the  face,  other  than  those  already 
dealt  with,  will  be  considered  under  the  follow- 
ing heads  :  (1)  The  face  generally;  (2)  the  paro- 
tid region;  and  (3)  the  upper  and  lower  Jaws 
and  parts  connected  with  them.  The  lips  will  be 
considered  with  the  "  cavity  of  the  mouth  ,; 
(chap.    viii.). 

1.  The  face  generally. — The  skin  of  the  face 
is  thin  and  fine,  and  is  more  or  less  intimately 
adherent  by  a  delicate  subcutaneous  tissue  to  the 
parts  beneath.  The  skin  generally  is  very  freely 
supplied  with  sebaceous  and  sudoriparous  glands, 
and  hence  the  face  is  very  commonly  the  seat  of 
acne,  an  eruption  that  specially  involves  the  seba- 
ceous follicles.  It  happens  from  the  thinness  of 
tne  skin,  and  from  the  absence  of  dense  fascia, 
that  facial  abscesses  usually  soon  point  and  sel- 
dom attain  large  size. 

The  cellular  tissue  of  the  face  is  lax,  and 
readily  lends  itself  to  spreading  infiltrations,  so 
that  in  certain  inflammatory  affections  the  cheeks 
and  other  parts  of  the  face  may  become  greatly 
swollen.  In  general  dropsy,  also,  the  face  soon 
becomes  "  puffy, "  the  change  first  appearing,  as 
a  rule,  in  the  lax  tissue  of  the  lower  lid.  The 
skin  over  the  chin  is  peculiarly  dense  and  adherent 
to  the  parts  beneath,  and  in  most  respects  closely 
resembles  the  integument  of  the  scalp.  When  such 
parts   of    the    integuments    of    the    face    as   cover 

111 


112  SURGICAL    APPLIED    ANATOMY       LPart  I 

prominent  bones,  as  the  parts  over  the  malar  bone, 
the  chin,  and  the  upper  lid,  are  struck  by  a 
blunt  instrument  or  in  a  fall,  the  wound  pro- 
duced has  often  the  appearance  of  a  clean  incised 
wound,  just  as  obtains  in  contused  wounds  of  the 
scalp. 

The  mobility  of  the  facial  tissues  renders  this 
part  very  suitable  for  the  performance  of  plastic 
operations  of  various  kinds,  and  their  vascularity 
generally  ensures  a  ready  and  sound  healing. 
Although  there  is  a  large  quantity  of  fat  in  the 
subcutaneous  tissue  of  this  region,  yet  fatty 
tumours  are  singularly  rare  upon  the  face.  They 
appear,  indeed,  to  avoid  this  region.  Thus  M. 
Denay  reports  the  case  of  a  man  who  had  no  less 
than  215  fatty  tumours  over  different  parts  of 
his  body,  but  not  one  upon  his  face.  The  face  is 
peculiarly  liable  to  be  the  seat  of  certain  ulcers, 
especially  the  rodent  and  lupoid  ulcer,  and  is  the 
part  most  often  attacked  by  "  malignant  pustule/' 
a  disease  transmitted  to  man  from  cattle  afflicted 
with  a  malady  known  in  this  country  as  "  mur- 
rain," and  in  France  as  "  charbon.,; 
*  Blood  supply. — The  tissues  of  the  face  are 
very  vascular,  and  are  liberally  supplied  with 
blood-vessels  in  all  parts.  The  finer  vessels  of  the 
skin  often  appear  permanently  injected  or  vari- 
cose in  the  drunken,  or  in  those  who  are  exposed 
to  cold,  or  are  the  subjects  of  certain  forms  of 
acne.  Thus,  nasvi,  and  the  various  forms  of  erec- 
tile tumour,  are  common  about  the  face.  For  a 
like  reason  also  wounds  of  the  face,  while  they 
may.  bleed  readily  when  inflicted,  are  apt  to  heal 
with  singular  promptness  and  accuracy.  All 
wounds,  therefore,  of  this  part  should  have  their 
edges  carefully  adjusted  as  soon  after  the  accident 
as  possible.  Extensive  flaps  of  skin  that  have 
been  torn  up  in  lacerated  wounds  often  retain 
their  vitality  in  almost  as  marked  a  manner  as 
do  like  flaps  torn  from  the  scalp.  ExtensiVe  in- 
juries to  the  face  associated  with  great  loss  of 
substance   are  often   repaired  in  a  most  remark- 


Chap.  VII]  THE    FACE  113 

able  manner,  as  has  been  illustrated  in  gunshot 
wounds  where  a  considerable  portion  of  the  face 
and  upper  jaw  has  been  blown  away.  The  low 
mortality  after  severe  injuries  to  the  face  is  due, 
however,  not  only  to  the  excellent  powers  of  re- 
pair the  part  possesses,  but  also  to  the  fact  that 
the  face  contains  no  organs  essential  to  life,  that 
its  bones  are  soft  and  thin  and  do  not  favour 
extensive  splitting,  and  that  there  are  several 
passages  and  cavities  in  the  region  through  which 
discharges  may  escape.  One  of  the  most  terrible 
instances  of  injury  not  immediately  fatal  is  re- 
ported by  Longmore  :  "  An  officer  of  Zouaves, 
wounded  in  the  Crimea,  had  his  whole  face  and 
lower  jaw  carried  away  by  a  ball,  the  eyes  and 
tongue  included,  so  that  there  remained  only  the 
cranium,  supported  by  the  neck  and  spine/'  He 
lived  twenty  hours. 

The  pulsations  of  the  facial  artery  can  be  best 
felt  at  the  lower  border  of  the  jaw,  where  the 
vessel  crosses  just  in  front  of  the  anterior  border 
of  the  masseter  muscle.  It  is  here  covered  only 
by  the  integument  and  platysma,  and  can  be 
readily  compressed  against  the  bone  or  ligatured. 
The  anastomoses  of  the  artery  upon  the  face  are 
so  free  that  when  the  vessel  is  divided,  both  ends, 
as  a  rule,  require  to  be  secured.  The  facial  vein 
is  only  in  contact  with  the  artery  near  the  lower 
border  of  the  jaw ;  on  the  face  it  is  separated  from 
it  by  a  considerable  interval.  The  vein  is  not  so 
flaccid  as  are  most  superficial  veins;  it  remains 
more  patent  after  section,  it  possesses  no  valves, 
and  communicates  at  one  end  indirectly  with  the 
cavernous  sinus,  and  at  the  other  with  the  inter- 
nal jugular  vein  in  the  neck.  This  vein  has  also 
another,  but  less  direct,  communication  with  the 
intracranial  veins.  It  is  as  follows  :  the  facial  vein 
receives  the  "  deep  facial  vein  ;;  from  the  ptery- 
goid plexus,  and  this  plexus  communicates  with 
the  cavernous  sinus  by  means  of  some  small  veins 
which  pass  through  the  foramen  ovale  and  the 
fibrous   tissue    of   the   foramen   lacerum   medium. 


114 


SURGICAL    APPLIED    ANATOMY       [Part  I 


These  dispositions  of  the  facial  vein  may  serve 
to  explain  the  mortality  of  some  inflammatory 
affections  of  the  part.  Thus  carbuncle  of  the  face 
is  not  unfrequently  fatal  by  inducing  thrombosis 
of  the  cerebral  sinuses,  and  a  like  complication 
may  occur  in  any  other  diffuse  and  deeply  extend- 
ing inflammatory  condition.  The  unusual  patency 
also  of  the  facial  vein  favours  septic  absorption, 
and  its  direct  communication  with  the  great  vein 


Fig.  24.—  Sh owing  the  development  of  the  face.    (Modified  from  Merke  . 

f.x.p.,  Part  formed  from  the  fronto-nasal  process ;  l.,  from  its  lateral  and  M.,from 
its  mesial  parts ;  max.,  formed  by  the  maxillary  process ;  man.,  formed  by  the 
mandibular  process. 

in  the  neck  may  explain  those  abrupt  deaths  from 
thrombosis  that  have  followed  upon  the  injection 
of  facial  nsevi  in  infants. 

A  reference  to  the  development  of  the  face 
assists  to  explain  the  distribution  of  the  fifth 
nerve  and  the  occurrence  of  certain  abnormalities 
(Fig.  24).  The  face  is  developed  from  five  pro- 
cesses, a  mesial,  the  fronto-nasal,  and  two  lateral 
— the  maxillary  and  mandibular.  The  fronto- 
nasal process  forms  the  middle  part  of  the  upper 
lip  and  the  nose.  It  may  fail  to  develop  :  thus 
the  condition  of  cyclops  is  produced.     It  springs 


Chap.  VII]  THE    FACE  115 

from  the  frontal  region  and  carries  with  it  a 
branch  of  the  first  division  of  the  fifth,  the  nasal 
nerve.  The  second  division  of  the  fifth  is  the 
nerve  of  the  maxillary  process,  while  the  third  is 
that  of  the  mandibular. 

JVerve  supply.— The  nerves  of  the  face  are 
very  liberally  distributed,  the  fifth  being  the  sen- 
sory nerve,  the  facial  the  motor  (Fig.  4,  p.  15). 
It  follows,  from  the  great  number  of  nerve  fila- 
ments about  the  part,  and  the  extensive  sensory 
nucleus  of  the  fifth  nerve,  that  severe  irritants 
applied  to  the  face  may  set  up  a  widespread  nerve 
disturbance.  Dr.  George  Johnson  mentions  a  case 
where  a  piece  of  flint  embedded  in  a  scar  on  the 
cheek  set  up  facial  neuralgia,  facial  paralysis, 
and  trismus,  and  induced  a  return  of  epileptic 
attacks.  The  positions  of  the  supra-  and  infra- 
orbital foramina  and  of  the  mental  foramen  and 
of  the  exit  of  the  corresponding  nerves  are  indi- 
cated as  follows  :  _  The  supraorbital  foramen  is 
found  at  the  junction  of  the  inner  with  the  middle 
third  of  the  upper  margin  of  the  orbit.  A  straight 
line  drawn  downwards  from  this  point  so  as  to 
cross  the  gap  between  the  two  bicuspids  in  both 
jaws  will  cross  both  the  infraorbital  and  mental 
foramina.  The  infraorbital  foramen  is  a  little 
over  \  of  an  inch  below  the  margin  of  the  orbit. 
The  mental  foramen  in  the  adult  is  midway  be- 
tween the  alveolus  and  the  lower  border  of  the 
jaw,  and  is  a  little  over  \  of  an  inch  below  the 
cul-de-sac  of  mucous  membrane  between  the  lower 
lip  and  jaw.  At  puberty  the  foramen  is  nearer 
to  the  lower  border  of  the  maxilla,  and  in  old  age 
it  is  close  to  the  alveolus.  The  infraorbital  nerve 
has  been  divided  for  neuralgia  at  its  point  of  exit, 
the  nerve  being  reached  either  by  external  incision 
or  through  the  mouth  by  lifting  up  the  cheek.  In 
other  cases  the  floor  of  the  orbit  has  been  exposed, 
the  infraorbital  canal  (the  anterior  half  of  which 
has  a  bony  roof)  has  been  opened  up,  and  large 
portions  of  the  trunk  of  the  nerve  have  been  in 
this   way   resected.      Meckel's   ganglion   has    been 


116  SURGICAL    APPLIED    ANATOMY       [Part  I 

repeatedly  excised  for  the  relief  of  neuralgia  in- 
volving the  second  division  of  the  fifth  nerve.  A 
triangular  flap  of  skin  is  turned  up  from  the  front 
of  the  cheek,  and  the  infraorbital  foramen  is  ex- 
posed. The  anterior  wall  of  the  antrum  is  opened 
with  a  trephine,  and  the  bone  is  cut  away  from 
the  floor  of  the  infraorbital  groove  so  that  the 
nerve  lying  in  that  canal  is  fully  exposed.  The 
nerve  is  followed  back  to  the  posterior  wall  of  the 
antrum.  This  wall  having  been  trephined,  the 
spheno-maxillary  fossa  is  opened  up  and  Meckel's 
ganglion  exposed.  Beyond  the  ganglion  the  fora- 
men rotundum  can  be  made  out.  The  infraorbital 
artery  runs  with  the  nerve,  and  that  vessel,  to- 
gether with  its  anterior  dental  branch  to  the 
incisor  and  canine  teeth,  will  probably  be  divided. 
The  infraorbital  vein  ends  in  the  pterygoid 
plexus.  The  ganglion  is  surrounded  by  the  ter- 
minal branches  of  the  internal  maxillary  artery. 
It  is  a  triangular  body,  with  a  diameter  of  about 
i  of  an  inch.  It  is  a  little  convex  on  its  outer 
side,    and  is   of   reddish   colour. 

The  inferior  dental  nerve  has  been  divided  at 
the  mental  foramen  by  an  incision  made  through 
the  mucous  membrane.  Through  this  incision  the 
nerve  can  be  stretched  and  the  cutaneous  portion 
of  it  excised.  Its  trunk  has  been  reached,  and  a 
part  excised,  through  a  trephine  hole  made  in  the 
body  of  the  lower  jaw.  This  operation,  however, 
inflicts  great  damage  upon  the  bone,  and  cannot  be 
recommended.  The  artery,  moreover,  is  liable  to 
be  wounded. 

The  nerve  has  been  divided  also  before  its  entry 
into  the  mental  foramen  in  the  following  manner  : 
The  mouth  being  held  widely  open,  an  incision  is 
made  from  the  last  upper  molar  to  the  last  lower 
molar  just  to  the  inner  side  of  the  anterior  bor- 
der of  the  coronoid  process,  which  can  be  clearly 
defined  by  palpation.  The  cut  passes  through  the 
mucous  membrane  down  to  the  tendon  of  the  tem- 
poral muscle.  The  finger  is  introduced  into  the 
incision,    and   passed   between   the   ramus   of   the 


Chap.  VII j  THE    PACE  117 

jaw  and  the  internal  pterygoid  muscle  until  the 
bony  point  is  felt  that  marks  the  orifice  of  the 
dental  canal.  The  nerve  is  here  picked  up  with 
a  hook,    isolated,   and   divided. 

The  buccal  nerve  may  be  the  seat  of  severe 
neuralgia,  and  may  be  thus  divided  through  the 
mouth  :  "  The  surgeon  places  the  finger-nail  upon 
the  outer  lip  of  the  anterior  border  of  the  ascend- 
ing ramus  of  the  lower  jaw  at  its  centre,  and 
divides  in  front  of  this  border  the  mucous  mem- 
brane and  the  fibres  of  the  buccinator  vertically. 
He  then  seeks  for  the  nerve,  separating  the  tissues 
with  a  director,  and  divides  it ;;  (Stimson). 

The  trunk  of  the  third  division  of  the  fifth 
nerve  has  been  divided  at  the  foramen  ovale 
through  a  flap  wound  made  in  the  cheek.  Con- 
siderable damage  of  the  soft  parts  results.  The 
position  of  the  foramen  ovale  may  be  marked  on 
the  surface  of  the  head  by  taking  a  point  on  the 
lower  border  of  the  zygoma  immediately  in  front 
of  the  eminentia  articularis  (see  Fig.  26). 

When  a  sensory  nerve  is  divided  the  area 
of  analgesia  which  results  does  not  correspond 
to  its  anatomical  distribution.  Thus,  when  the 
ophthalmic  division  of  the  fifth  cranial  nerve  is 
cut,  only  a  narrow  strip  of  skin  on  the  forehead  is 
completely  deprived  of  feeling,  whereas  from  the 
anatomical  distribution  one  would  infer  that  the 
skin  of  the  forehead  and  of  the  anterior  half  of  the 
scalp  should  be  involved  (see  Fig.  4,  p.  15).  If  the 
second  division  is  cut,  the  area  of  anaesthesia  is 
confined  to  a  narrow  space  between  the  orbit  and 
the  mouth ;  on  section  of  the  third  division,  to  a 
strip  running  downwards  in  front  of  the  ear  and 
along  the  course  of  the  lower  jaw  (Head). 

Head  has  lately  offered  an  explanation  of  the 
varying  results  which  follow  section  of  a  sensory 
nerve.  A  nerve  contains  three  kinds  of  sensory 
nerve  fibres  :  (1)  those  subserving  deep  sensibility 
— endowing  muscles,  bones,  ligaments,  joints,  and 
deep  structures  with  the  power  to  feel  pressure  and 
pain;  (2)  those  subserving  protopatliic  sensibility^ 


118 


SURGICAL    APPLIED    ANATOMY       [Part  I 


by  which  the  skin  is  rendered  sensitive  to  prick 
and  to  temperature,  if  it  be  above  40°  or  below 
22° ;  (3)  those  subserving  epicritic  sensibility — by 
which  the  skin  is  endowed  with  the  power  of  feel- 
ing light  touch — tested  with  such  a  substance  as 
cotton  wool — and  finer  degrees  of  temperature. 
Now,  in  the  majority  of  instances,  when  a  nerve  is 
divided,  the  loss  of  epicritic  sensibility  corresponds 
in  extent  to  the  anatomical  distribution  of  the 
nerve ;  when  the  Gasserian  ganglion  is  removed 
{see  Figs.  4  and  25)  the  loss  of  epicritic  sensibility 


Fig.  25. — The  extent  of  loss  of  sensibility  following  (a)  excision  of  the 
Gasserian  ganglion  ;  (b)  section  of  the  second  cervical  nerve.  {After 
H.  H.  Tooth.) 

In   the  area  stippled  black  there  is  a   loss  of  protopathic  sensibility ;  in  that 
stippled  red,  of  epicritic  sensibility. 

corresponds  to  the  area  of  distribution,  but  the  loss 
of  protopathic  sensibility  is  less  than  the  anatomi- 
cal area.  It  is  evident  that  protopathic  fibres  from 
the  second  cervical  nerve  (Fig.  25)  invade  and  sup- 
ply the  area  of  skin  furnished  with  epicritic  sen- 
sibility by  the  fifth  nerve.  In  the  lower  part  of  the 
face  there  is  no  overlapping  of  areas  ;  in  the  mental 
branch  of  the  fifth,  the  epicritic  and  protopathic 
fibres  are  distributed  to  the  same  extent  of  skin. 
Thus  the  effects  which  follow  section  of  a  sensory 
nerve  depend  on  the  nature  of  the  fibres  in  that 
nerve,  and  on  the  extent  of  skin  to  which  each 
kind   is  exclusively   distributed. 


Chap.  VII] 


THE    FACE 


119 


Excision  of  the  Gasserian  ganglion. — For  cases 
of  intolerable  and  intractable  neuralgia  Rose  pro- 
posed the  excision  of  the  Gasserian  ganglion.  It 
is  the  sensory  ganglion  of  the  fifth  nerve,  and  cor- 
responds to  the  ganglion  on  the  posterior  root  of  a 
spinal  nerve.  The  nerve  fibres  of  the  fifth  neces- 
sarily undergo  degeneration  when  it  is  excised. 

The  operation  usually  performed  is  the  follow- 
ing (see  Fig.  26) :  An  omega-shaped  flap  of  skin  is 
raised  from   the    temples,   having  the   zygoma   at 


island  of  Ceil  & 
Fissureoc  Sylvius 
Deep  Temp.  Fascia 

Temp.  Muscle 
First  Temp. Fissure 
Uncus 
Dura  Mater. 
Aid  /Ie/iihqealArt 
Root  of  Zyqoma 
Ext  Pteryqoid 
Mid  ZiE/iinqEAL Art 
I/ht.  Max.  Art 
Masseter 
Ccronoid  Proc 


Optic  Tract 
Subarachnoid  Space 
IV* 

Cavernous  Simus 
Int  Carotid  Art. 


VI 


rb 


C.ASSER.IAN  C.ANC.LION 

Sphenoidal  Sinus 
3rd  Div.  of  Vfh 
Lat.  Recess  of  Phar. 
Eustachian  Tube- 
Levator.  Palatae 


Fig. 


-Coronal  section  to  show  the  depth   and  relationships   of  the 
Gasserian  ganglion. 


its  base  and  the  temporal  ridge  at  its  convexity. 
The  tissues  are  reflected  down  to  the  floor  of  the 
temporal  fossa.  The  superficial  and  deep  temporal 
vessels  have  to  be  tied.  A  wide  trephine  opening  is 
made  in  the  squamosal  and  great  wing  of  the 
sphenoid  on  a  level  with  the  upper  border  of  the 
zygoma,  and  the  dura  mater  exposed.  This  is 
usually  followed  by  profuse  haemorrhage  from  the 
middle  meningeal  vessels  which  cross  the  field  of 
operation.  The  dura  mater  and  the  superimposed 
temporo-sphenoidal  lobe  are  raised  from  the  bone, 
when  the  third  and  second  divisions  of  the  fifth 


120  SURGICAL    APPLIED    ANATOMY       [Part  I 

nerve  are  brought  into  view  as  they  escape  by  the 
foramen  ovale  and  foramen  rotundum.  They  are 
seen  to  spring  from  the  Gasserian  ganglion  situ- 
ated over  the  apex  of  the  petrous  bone  and  on  the 
outer  wall  of  the  cavernous  sinus.  The  motor  root 
which  supplies  the  muscles  of  mastication  lies 
under  the  ganglion  and  should  not  be  cut.  The 
ganglion  is  embedded  in  the  dura  mater  and  sur- 
rounded by  a  prolongation  of  the  subarachnoid 
space  (Meckel's  space),  which  is  necessarily  opened. 
Only  the  part  of  the  ganglion  connected  with  the 
second  and  third  divisions  is  removed,  the  part 
connected  with  the  ophthalmic  division  being  left, 
as  it  is  firmly  embedded  in  the  outer  wall  of  the 
cavernous  sinus  and  in  close  proximity  to  the  inter- 
nal carotid  artery  and  the  oculo-motor  nerves. 
The  hippocampal  convolution  containing  the  olfac- 
tory centre  lies  immediately  over  the  ganglion 
(Fig.  26). 

The  eminentia  articularis  at  the  base  of  the 
zygoma  serves  as  a  useful  guide  to  the  position 
of  the  ganglion  ;  when  the  middle  fossa  is  opened 
and  the  temporal  lobe  raised  up  the  ganglion  will 
be  found  at  a  depth  of  2^  inches  and  in  the  same 
coronal  plane  as  the  articular  eminence,  but  at  a 
higher  level.* 

The  malar  bone.— Such  is  the  firmness  ot 
this  bone,  and  so  direct  is  its  connection  with  the 
skull,  that  violent  blows  upon  it  are  very  apt  to  be 
associated  with  concussion.  Resting  as  it  does  upon 
comparatively  slender  bones,  it  is  very  rare  for  the 
malar  bone  to  be  broken  alone.  It  may,  indeed,  be 
driven  into  the  superior  maxillary  bone,  fracturing 
that  structure  extensively,  without  being  itself  in 
any  way  damaged.  A  fracture  of  the  malar  bone 
may  lead  to  an  orbital  ecchymosis,  precisely  like 
that  which  often  attends  a  fracture  of  the  skull 
base. 

2.  The  parotid  region. — The  main  part 
of  the  parotid  gland  is  lodged  in  a  definite  space  be- 

*  For  a  full  account  of  the  anatomy  of  this  operation  see  "The  Surgical 
Treatment  of  Facial  Neuralgia,"  by  J.  Hutchinson,  jun.     London,  1905. 


Chap.  VII] 


ill  i :   iwci: 


121 


hind  the  ramus  of  the  lower  jaw  (Fig.  27).  This  space 
is  increased  in  size  when  the  head  is  extended, 
and  when  the  inferior  maxilla  is  moved  forwards, 


Fig.  27. — A  horizontal  section  through  one  side  of  the  face  and  neck  just 
above  the  level  of  the  lower  teeth.     (Braune.) 

a,  Facial  artery;  b,  facial  vein;  c,  gustatory  nerve;  c?,  inferior  dental  nerve  and 
artery  lying  internally  to  the  ascending  ramus  of  jaw  ;  e,  styloid  process ; 
/,  internal  carotid  artery:  g,  internal  jugular  vein,  with  the  vagus,  spinal 
accessory,  and  hypoglossal  nerves  to  its  inner  side  ;  h,  vertebral  artery. 
Externally  to  the  ascending  ramus  is  shown  the  masseter  ;  internally  to  it  the 
internal  pterygoid  •  internally  to  the  last-named  muscle,  the  superior  con- 
strictor and  tonsil. 


122  SURGICAL    APPLIED    ANATOMY       [Part  I 

as  in  protruding  the  chin.  In  the  latter  movement, 
the  increase  in.  the  antero-posterior  direction  is 
equal  to  about  f  of  an  inch.  It  is  diminished  when 
the  head  is  flexed.  When  the  mouth  is  widely 
opened  the  space  is  diminished  below,  while  it  is 
increased  above  by  the  gliding  forwards  of  the  con- 
dyle. These  facts  should  be  borne  in  mind  in 
operating  upon  and  in  exploring  the  parotid  space. 
It  will  be  found  also  that  in  inflammation  of  the 
parotid  much  pain  is  produced  by  all  those  move- 
ments that  tend  to  narrow  the  space  occupied  by 
the  gland.  The  obliquity  of  the  ramus  of  the  jaw 
in  infancy  and  old  age  causes  the  lower  part  of  the 
space  to  be,  in  the  former  instance  relatively  and 
in  the  latter  instance  actually,  larger  than  it  is 
in  the  adult. 

The  gland  is  closely  invested  by  a  fascia  derived 
from  the  cervical  fascia.  The  superficial  layer  of 
the  parotid  fascia  is  very  dense,  continuous  be- 
hind with  the  fibrous  sheath  of  the  sterno-mastoid, 
and  in  front  with  that  of  the  masseter.  Above  it 
is  attached  to  the  zygoma,  while  below  it  joins 
the  deep  layer.  The  deep  layer  is  slender,  is 
attached  to  the  styloid  process,  forms  the  stylo- 
maxillary  ligament,  and  is  connected  with  the 
sheaths  of  the  pterygoid  muscles  and  the  pterygoid 
process.  The  gland  is,  therefore,  encased  in  a  dis- 
tinct sac  of  fascia,  which  is  entirely  closed  below, 
but  is  quite  open  above.  Between  the  anterior 
edge  of  the  styloid  process  and  the  posterior  bor- 
der of  the  internal  pterygoid  muscle  there  is  a  gap 
in  the  fascia,  through  which  the  parotid  space  com- 
municates with  the  connective  tissue  about  the 
pharynx.  It  is  well  known  that  in  postpharyngeal 
abscesses  there  is  very  usually  a  parotid  swelling, 
and  in  several  instances  the  pus,  or  at  least  some 
portion  of  it,  has  been  evacuated  in  the  parotid 
region.  In  these  cases  the  matter  most  probably 
extends  from  the  pharyngeal  to  the  parotid  region 
through  the  gap  just  described.  From  the  disposi- 
tion of  the  fascia  it  follows  that  very  great  resist- 
ance is  offered  to  the  progress  of  a  iiarotid  abscess 


Chap.  VII]  THE    FACE  123 

directly  outwards  through  the  skin.  The  abscess 
often  advances  upwards  to  the  temporal,  or  zygo- 
matic fossae,  in  the  direction  of  least  resistance,  al- 
though progress  in  that  line  is  resisted  by  gravity. 
It  frequently  makes  its  way  towards  the  buccal 
cavity  or  pharynx,  or  it  may  break  through  the 
lower  limits  of  the  fascia  and  reach  the  neck.  It 
must  be  borne  in  mind  that  the  gland  is  in  direct 
contact  with  the  cartilaginous  meatus,  with  the 
ramus  of  the  jaw  and  other  bony  parts,  and  is 
closely  related  to  the  temporo-maxillary  joint. 
Thus,  a  parotid  abscess  has  burst  into  the  meatus, 
has  led  to  periostitis  of  the  bones  adjacent  to  it, 
and  has  incited  inflammation  in  the  joint  of  the 
lower  jaw. 

In  several  cases  reported  by  Yirchow  the  pus 
appears  to  have  found  its  way  into  the  skull  along 
branches  of  the  fifth  nerve,  for  the  environs  of  the 
Gasserian  ganglion  were  found  infiltrated  with 
pus.  The  auriculo-temporal  and  great  auricular 
nerves  supply  the  gland  with  sensation,  and  the 
presence  of  these  nerves,  together  with  the  unyield- 
ing character  of  the  parotid  fascia,  serves  to  ex- 
plain the  great  pain  felt  in  rapidly  growing 
tumours  and  acute  inflammation  of  the  gland. 
The  pain  is  often  very  distinctly  referred  along 
the  course  of  the  auriculo-temporal  nerve.  Thus, 
a  patient  with  parotid  growth  under  my  care 
had  pain  in  those  parts  of  the  pinna  and  temple 
supplied  by  the  nerve,  pain  deep  in  the  meatus,  at 
a  spot  that  would  correspond  to  the  entrance  of 
the  meatal  branch  of  the  nerve,  and  pain  in  the 
joint  of  the  lower  jaw,  which  is  supplied  by  the 
auriculo-temporal.  . 

The  most  important  structures  in  the  gland  are 
the  external  carotid  artery,  with  its  two  terminal 
branches,  and  the  facial  nerve.  The  artery,  as  Til- 
laux  has  pointed  out,  is  behind  the  ramus  of  the 
jaw,  as  high  up  as  the  junction  of  the  inferior  with 
the  middle  third  of  its  posterior  border.  It  then 
enters  the  parotid  gland,  and,  passing  a  little 
backwards    and    outwards,    comes    nearer    to    the 


124 


SURGICAL    APPLIED    ANATOMY       [Part  I 


surface,  and  at  the  level  of  the  condyle  of  the  jaw 
breaks  into  its  two  terminal  branches.  The  artery, 
therefore,  does  not  enter  the  gland  at  its  inferior 
border,  and  is  not  in  actual  relation  with  the 
parotid  space  at  its  lowest  part.  The  vessel,  more- 
over, is  not  parallel  with  the  edge  of  the  ramus, 
but  passes  through  the  parotid  gland  with  some 
obliquity. 


Sup  Temp.Art. 
Ext.  Auditory /I  eatus 
1/xf.Max.Ar.t 
Styloid  Pp-OC. 
Facial  /Ieeve 


^=^SPinAL  Accessory  /i. 

^SZd/  AlypoQLoasAL  N. 
/X  x/ 

Ste/nsom's  Duct 

Ext  Carotid  Art 


AlypocLOsSAL  /leave 
Qreat  /Ior/i  o/AlyOlD 


Fig.  28. — Surface  markings  of  the  facial,  spinal  accessory,  and  hypoglossal 

nerves. 

a,  Mid  point  of  anterior  border  of  mastoid  process ;  b,  point  on  anterior  border  oi 
seer  no-mast  oid,  one  inch  below  mastoid  process ;  c,  mid  point  of  posterior 
border  of  sterno-mastoid.  Above  b  the  transverse  process  of  the  atlas  is 
indicated. 


At  its  point  of  exit  from  the  base  of  the 
skull  by  the  stylo-mastoid  foramen,  the  facial 
nerve  lies  1  inch  deep  to  the  mid  point  of  the 
anterior  border  of  the  mastoid  process ;  a  line 
drawn  horizontally  forwards  from  that  point  to 
the  posterior  border  of  the  ascending  ramus  of  the 
mandible  marks  the  position  of  the  main  trunk  of 
the  nerve  (Fig.  28).  Within  the  gland,  where  the 
nerve  divides  into  its  temporo-facial  and  cervico- 


Chap.  VII]  THE    FACE  125 

facial  divisions,  it  is  superficial  to  both  the  ex- 
ternal carotid  artery  and  temporo-maxillary  vein. 
The  nerve  has  been  stretched  close  to  its  point  of 
exit  from  the  stylo-mastoid  foramen  for  the  relief 
of  facial  tic.  It  is  best  found  at  a  spot  about  ^  of 
an  inch  in  front  of  the  centre  of  the  anterior 
border  of  the  mastoid  process.  It  will  be  found 
above  the  posterior  belly  of  the  digastric,  which 
serves  as  a  guide  to  it  in  the  depth  of  the  wound. 

Section  of  the  facial  nerve  causes  paralysis  of 
the  buccinator  and  of  all  the  muscles  of  expres- 
sion, the  mouth  being  pulled  towards  the  sound 
side  and  the  eye  remaining  unclosed.  To  restore 
mobility  to  the  face  in  cases  of  palsy,  surgeons 
have,  in  a  number  of  recent  instances,  sutured  the 
facial  to  the  trunk  of  a  neighbouring  nerve — 
the  trunks  selected  being  the  spinal  accessory  and 
hypoglossal  (Fig.  28).  In  the  one  case  the  muscles 
of  expression  are  thrown  into  action  when  the 
trapezius  and  sterno-mastoid  are  used;  in  the 
other  when  the  tongue  is  moved.  In  course  of  time 
the  patient  may  become  able  to  dissociate  these  in- 
conveniently combined  movements.  At  its  point 
of  exit  the  facial  nerve  gives  off  its  posterior 
auricular  branch  to  the  muscles  of  the  ear  and 
twigs  to  the  posterior  belly  of  the  digastric  and 
stylo-hyoid  muscles. 

It  follows,  from  the  complex  relations  of  the 
parotid,  that  its  entire  removal  as  a  surgical  pro- 
cedure is  an  anatomical  impossibility.  In  open- 
ing a  parotid  abscess  a  cut  is  usually  made  over  the 
angle  of  the  jaw,  and  a  director  pushed  upwards 
into  the  substance  of  the  gland,  after  the  plan  ad- 
vised by  Hilton.  The  gland  is  separated  by  a  mere 
layer  of  fascia  from  the  internal  carotid  artery,  the 
internal  jugular  vein,  the  vagus,  glosso-pharyn- 
geal,  and  hypoglossal  nerves  (Fig.  27).  Thus,  in 
stabs  in  the  parotid  region  it  may  be  difficult  at 
first  to  tell  whether  the  internal  or  the  external 
carotid  is  wounded.  It  has  been  suggested  that 
the  cerebral _  hyperemia  sometimes  noticed  in 
severe    parotitis    (mumps)    may    be    clue    to    the 


126  SURGICAL    APPLIED    ANATOMY       [Part  I 

pressure  of  the  enlarged  gland  upon  the  internal 
jugular  vein. 

Tumours  of  the  parotid  are  very  apt  to  contain 
cartilaginous  tissue.  It  is  well  known  that  meta- 
stases after  mumps  are  quite  common  in  the  testis. 
It  is  significant  in  this  connection  that  the  testis 
is  one  of  the  few  parts  of  the  body,  apart  from  bone, 
where  cartilaginous  matter  forms  a  frequent  con- 
stituent of  the  neoplasms  of  the  part.  Mr.  Paget 
has  pointed  out  that  inflammation  of  the  parotid 
is  peculiarly  frequent  after  injuries  and  diseases 
of  the  abdomen  and  pelvis.  It  occurs  also  very 
often  as  a  sequela  of  some  specific  fevers,  but  more 
especially  after  typhoid.  The  anatomical  or  physio- 
logical basis  of  this  connection  has  not  been  made 
out. 

Many  lymphatic  glands  are  placed  upon  the 
surface  and  in  the  substance  of  the  parotid  gland. 
They  receive  lymph  from  the  frontal  and  parietal 
regions  of  the  scalp,  from  the  orbit,  the  posterior 
part  of  the  nasal  fossae,  the  upper  jaw,  and  the 
hinder  and  upper  part  of  the  pharynx.  When  en- 
larged these  glands  may  form  one  species  of 
"parotid  tumour." 

Stenson's  duct  (Fig.  28)  is  about  %\  inches 
long,  and  has  a  diameter  of  |th  of  an  inch,  its 
orifice  being  the  narrowest  part.  At  the  anterior 
border  of  the  masseter  muscle  the  duct  bends 
suddenly  inwards  to  pierce  the  buccinator  muscle. 
The  bend  is  so  abrupt  that  the  buccal  segment  of 
the  duct  may  be  almost  at  right  angles  with  the 
masseteric.  This  bend  should  be  taken  into  con- 
sideration in  passing  a  probe  along  the  duct  from 
the  mouth.  The  duct  opens  on  the  summit  of  a 
papilla  placed  on  a  level  with  the  second  upper 
molar  tooth.  The  course  of  the  duct  across  the 
masseter  is  represented  by  a  line  drawn  from  the 
lower  margin  of  the  concha  to  a  point  midway 
between  the  ala  of  the  nose  and  the  red  margin  of 
the  lip.  It  lies  about  a  finger-breadth  below  the 
zygoma,  having  the  transverse  facial  artery  above 
it  and  the  infraorbital  branches  of  the  facial  nerve 


Chap.  VIII  THE    FACE  127 

below  it.  The  duct  has  been  ruptured  subcutane- 
ously,  leading  to  extravasations  of  saliva.  Wounds 
of  the  duct  are  apt  to  lead  to  salivary  fistulse. 
When  the  fistula  involves  the  buccal  segment  of 
the  duct  it  may  be  cured  by  opening  the  duct  into 
the  mouth  on.  the  proximal  side  of  the  fistula. 
Fistula?  of  the  masseteric  segment  are,  on  the 
other  hand,  very  difficult  to  relieve^  At  least  one- 
half  of  the  buccal  part  of  the  duct  is  embedded  in 
the  substance  of  the  buccinator  muscle.  A  salivary 
fistula  over  the  masseter  may  involve  the  parotid 
gland  itself,  or  that  part  of  it  known  as  the  socia 
parotidis.  Inflammatory  conditions  may  spread 
to  the  parotid  from  the  mouth  along  Stenson's 
duct. 

3.  The  upper  and  lower  jaws,  and  parts 
connected  with  them. 

The  superior  maxilla  (for  antrum,  see  Nose, 
p.  109;  for  hard  palate,  see  Mouth,  p.  149). — This 
bone,  on  account  of  its  fragility  and  the  manner 
in  which  it  is  hollowed  out,  is  very  readily  frac- 
tured. The  fracture  may  be  due  to  direct  violence, 
as  by  a  blow  from  a  "knuckle-duster,"  or  it  may 
be  broken  by  a  force  transmitted  from  the  lower 
jaw  through  the  teeth,  as  in  cases  of  severe  blows 
or  falls  upon  the  chin.  It  may  be  broken  by  a  blow 
upon  the  head,  when  the  chin  is  fixed,  no  other  bone 
being  damaged  ;  and,  lastly,  it  may  be  crushed,  as 
above  stated,  by  the  driving  in  of  the  malar  bone. 
The  displacement  of  the  fragments  depends  upon 
the  direction  and  degree  of  the  force  employed, 
no  muscles  having  effect.  The  bone  being  very 
vascular,  serious  injuries,  involving  great  loss  of 
substance,  are  often  wonderfully  repaired.  Its 
hollowness  and  the  cavities  that  it  helps  to  bound 
render  it  possible  for  large  foreign  bodies  to  be  re- 
tained in  the  deeper  parts  of  the  face.  Thus, 
Longmore  reports  "the  case  of  Lieutenant  Fretz, 
of  the  Ceylon  Rifles,  who  was  able  to  do  his  mili- 
tary duties  for  nearly  eight  years  with  the  breech 
and  screw  of  a  burst  musket  lodged  in  the  nares, 
part  of  the  tail-pin  and  screw  protruding  through 


128  SURGICAL    APPLIED    ANATOMY       [Part  I 

the  hard  palate  into  the  mouth."  The  bone  may 
undergo  extensive  necrosis,  especially  in  that  form 
of  necrosis  induced  in  workers  in  match  factories 
by  exposure  to  the  fumes  of  phosphorus.  In  one 
case  (Med.  Times,  1862)  of  necrosis  following 
measles  the  mischief  was  limited  to  the  p re-maxil- 
lary, or  incisive  bone. 

The  periosteum  of  the  superior  maxilla  is,  like 
the  pericranium,  not  disposed  to  form  new  bone.  In 
ordinary  cases  of  necrosis  of  the  upper  jaw  no  re- 
production of  bone  takes  place,  the  gap  being  left 
permanent.  In  the  lower  jaw  abundant  new  bone 
is  produced  -by  the  periosteum,  and  extensive 
losses  may  be  repaired.  It  is  remarkable,  however, 
that  in  course  of  years  this  new  bone  is  liable  to 
be  very  extensively  reabsorbed. 

Excision  of  the  superior  maxilla. — 
The  entire  bone  has  been  frequently  removed  when 
the  seat  of  an  extensive  tumour,  and  under  cer- 
tain other  conditions.  The  bony  connections  to  be 
divided  in  the  operation  are  the  following :  (1) 
The  connection  with  the  malar  bone  at  the  outer 
side  of  the  orbit;  (2)  the  connection  of  the  nasal 
process  with  the  frontal,  nasal,  and  lachrymal 
bones ;  (3)  the  connections  of  the  orbital  plate  with 
the  ethmoid  and  palate  (this  plate  is  often  left  be- 
hind, or  is  cut  through  near  the  orbital  margin) ; 
(4)  the  connection  with  the  opposite  bone  and  the 
palate  in  the  roof  of  the  mouth;  and  (5)  the  con- 
nection behind  with  the  palate  bone,  and  the 
fibrous  attachments  to  the  pterygoid  processes.  In 
the  four  first-named  instances  the  separation  is 
effected  by  a  cutting  instrument ;  in  the  last- 
named,  by  simply  twisting  out  the  bone. 

Soft  parts  divided:  These  may  be  considered 
under  three  heads  :  The  parts  cut  (l)  in  the  first 
incision;  (2)  in  turning  back  the  flap;  and  (3)  in 
separating  the  bone. 

(1)  The  following  are  the  parts  cut  in  order 
from  above  downwards  in  the  usual,  or  "  median, " 
incision,  an  incision  commencing  parallel  with  the 
lower  eyelid,  and  continued  down  the  side  of  the 


Chap.  VII]  THE    FACE  129 

nose,  round  the  ala,  and  through  the  middle  of  the 
upper  lip  :  Skin,  superficial  fascia,  orbicularis  pal- 
pebrarum, palpebral  branches  of  infraorbital  nerve 
and  artery,  part  of  lev.  labii  superioris,  angular 
artery  and  vein,  lev.  labii  sup.  alseque  nasi,  later- 
alis nasi  artery  and  vein,  nasal  branches  of  infra- 
orbital nerve,  compressor  naris,  depressor  alse  nasi, 
attachment  of  nasal  cartilage  to  bone,  orbicularis 
oris,  sup.  coronary  artery  and  vein,  and  mucous 
membrane  of  lip.  Various  branches  of  the  facial 
nerve  to  the  muscles  may  be  cut.  (2)  In  turning 
back  the  flap,  the  muscles  above  named  _wi.ll  be 
dissected  up,  together  with  the  tendo  oculi,  if  the 
nasal  process  is  removed  entire,  the  levator  anguli, 
the  buccinator,  a  few  fibres  of  the  masseter,  and, 
on  the  orbital  plate,  the  inferior  oblique  muscles. 
The  infraorbital  nerve  and  artery  will  be  cut  as 
they  leave  their  foramen.  In  the  flap  itself  will  be 
the  trunks  of  the  facial  artery  and  vein,  the  trans- 
verse facial  artery,  and  the  facial  part  of  the  facial 
nerve.  (3)  In  separating  the  nasal  process  the  lach- 
rymal sac  and  infratrochlear  nerve  will  be  dam- 
aged, and  the  nasal  duct  and  external  branch  of 
the  nasal  nerve  cut  across.  In  separating  the  bones 
below,  the  coverings  of  the  hard  palate  are  divided, 
and  the  attachment  of  the  soft  palate  to  the 
palate  bone,  unless  the  removal  of  that  process 
can  be  avoided.  "  Any  attempt  to  dissect  off  and 
preserve  the  soft  covering  of  the  hard  palate  is 
futile"  (Heath).  Posteriorly,  the  trunk  of  the 
infraorbital  nerve  is  again  divided  (this  time 
in  front  of  Meckel's  ganglion),  together  with 
the  posterior  dental  and  infraorbital  arteries, 
and  some  branches  of  the  spheno-palatine  artery. 
The  deep  facial  vein  from  the  pterygoid  plexus 
will  probably  be  cut,  and,  lastly,  near  the  palate 
will  also  be  divided  the  large  palatine  nerve  and 
the  descending  palatine  artery. 

It  will  be  seen  that  no  large  artery  is  divided  in 
the  operation.  The  inferior  turbinated  bone  comes 
away,   of  course,    with   the  maxilla. 

The  inferior  maxilla ;  fracture. — This  bone 


130  SUEGICAL    APPLIED    ANATOMY       [Part  I 

is  to  a  great  extent  protected  from  fracture  by  its 
horse-shoe  shape,  which  gives  it  some  of  the  pro- 
perties of  a  spring,  by  its  density  of  structure,  by 
its  great  mobility,  and  by  the  buffer-like  interarti- 
cular  cartilages  that  protect  its  attached  extremi- 
ties. The  bone  is  usually  broken  by  direct  violence, 
and  the  fracture  may  be  in  any  part.  The  sym- 
physis is  rarely  broken,  on  account  of  its  great 
thickness.  The  ramus  is  protected  by  the  muscu- 
lar pads  that  envelop  its  two  sides,  and  the  coro- 
noid  process  is  still  more  out  of  the  risk  of  injury, 
owing  to  the  depth  at  which  it  is  placed  and  the 
protection  it  derives  from  the  zygoma.  The  weak- 
est part  of  the  bone  is  in  front,  where  its  strength 
is  diminished  by  the  mental  foramen  and  by  the 
large  socket  required  for  the  canine  tooth.  It  is 
about  this  part,  therefore,  that  fracture  is  the  most 
common.  The  bone  may  be  broken  near,  or  even 
through,  the  symphysis  by  indirect  violence,  as  by 
a  blow  or  crushing  force  that  tends  to  approximate 
the  two  rami.  Thus,  the  jaw  has  been  broken  near 
the  middle  line  by  a  blow  in  the  masseteric  region. 
The  amount  of  displacement  in  fractures  of  this 
bone  varies  greatly,  and  is  much  influenced  by  the 
nature  and  direction  of  the  force.  In  general 
terms,  it  may  be  said  that  when  the  body  of  the 
bone  is  broken  the  anterior  fragment  is  drawn 
backwards  and  downwards  by  the  jaw  depressors, 
the  digastric,  mylo-hyoid,  genio-hyoid,  and  genio- 
hyo-glossus  ;  while  the  hinder  fragment  is  drawn 
up  by  the  elevators  of  the  jaw,  the  masseter,  inter- 
nal pterygoid,  and  temporal.  It  must  be  remem- 
bered that  the  mylo-hyoid  muscle  will  be  attached 
to  both  fragments,  and  will  modify  the  amount  of 
displacement.  Fractures  of  the  ramus  are  seldom 
attended  with  much  displacement,  muscular  tissue 
being  nearly  equally  attached  to  both  fragments. 

In  fractures  of  the  body  of  the  bone  the  dental 
nerve  often  marvellously  escapes  injury,  a  fact  that 
is  explained  by  the  supposition  that  the  bones  are 
not  usually  sufficiently  displaced  to  tear  across  the 
nerve.     Weeks  after  the  accident,    however,   the 


Chap.  VII]  THE    FACE  131 

nerve  has  become  so  compressed  by  the  developing 
callus  as  to  have  its  function  destroyed. 

One  or  both  condyles  have  often  been  broken 
by  falls  or  blows  upon  the  chin.  The  gums  being 
firm  and  adherent,  it  follows  that  they  are  usually 
torn  in  fractures  of  the  body  of  the  maxilla,  and 
hence  the  bulk  of  the  fractures  in  this  part  are  com- 
pound. 

The  temporo  -  maxillary  articulation  is 
supported  by  a  capsule  which  varies  greatly  in 
thickness  in  different  parts.  By  far  the  thickest 
part  of  the  capsule  is  the  external  part  (the  exter- 
nal lateral  ligament).  The  internal  part  is  next  in 
thickness,  while  the  anterior  and  posterior  por- 
tions of  the  capsule  are  thin,  especially  the  former, 
which  is  very  thin.  Thus,  when  this  joint  suppu- 
rates, the  pus  is  least  likely  to  escape  on  the  ex- 
ternal aspect  of  the  articulation,  and  is  most  likely 
to  find  an  exit  through  the  anterior  part  of  the  cap- 
sule, although  this  part  is  to  a  great  extent  pro- 
tected by  the  attachments  of  the  external  ptery- 
goid muscle.  Immediately  behind  the  condyle  of 
the  jaw  are  the  bony  meatus  and,  a  little  to  the 
inner  side,  the  middle  ear.  In  violent  blows  upon 
the  front  of  the  jaw  these  structures  may  be  dam- 
aged, and  it  is  interesting  to  note  that  the  strongest 
ligament  of  the  joint  (the  external  lateral)  has  a 
direction  downwards  and  backwards,  so  as  im- 
mediately to  resist  any  movement  of  the  condyle 
towards  the  slender  wall  of  bone  that  bounds  the 
meatus  and  tympanum.  Were  it  not  for  this  liga- 
ment, a  blow  upon  the  chin  would  be  a  much  more 
serious  accident  than  it  is  at  present. 

It  follows,  from  the  proximity  of  the  joint  to 
the  middle  ear,  that  disease  in  the  articulation  may 
be  a  result  of  middle-ear  disease.  In  one  case 
(Holmes's  "  System  of  Surgery"),  suppurative  dis- 
ease, spreading  from  the  middle  ear,  not  only  in- 
volved the  joint,  but  induced  necrosis  of  the  con- 
dyle of  the  lower  jaw.  The  necrosed  condyle  was 
removed  entire  from  the  auditory  meatus,  into 
which- cavity  it  had  projected. 


132  SUEGICAL    APPLIED    ANATOMY       [Part  I 

The  movements  of  this  joint  are  peculiar.  On 
opening  the  mouth  it  will  be  observed  that  the 
condyle  moves  forwards  and  downwards  upon  the 
articular  eminence,  while  the  angle  of  the  jaw 
moves  in  a  backward  and  upward  direction.  The 
axis  of  the  movement  is  a  transverse  line  drawn 
between  the  inferior  dental  foramina ;  thus,  it  will 
be  seen  that  the  inferior  dental  nerves  enter  the 
mandible  at  the  point  of  least  movement.  The  ex- 
ternal pterygoid  muscles,  by  pulling  the  condyle 
upon  the  articular  eminence,  take  the  chief  part 
in  opening  the  mouth  ;  at  the  same  time  the  chin 
is  depressed  by  the  contraction  of  the  mylo-hyoid 
and  digastric  muscles. 

Dislocation. — This  joint  permits  of  only  one 
form  of  dislocation,  a  dislocation  forwards.  It  may 
be  unilateral  or  bilateral,  the  latter  being  the  more 
usual,  and  it  can  only  occur  when  the  mouth  hap- 
pens to  be  wide  open.  Indeed,  the  dislocation  is 
nearly  always  due  to  spasmodic  muscular  action 
when  the  mouth  is  open,  although  in  some  few  cases 
it  has  been  brought  about  by  indirect  violence,  as 
by  a  downward  blow  upon  the  lower  front  teeth, 
the  mouth  being  widely  opened.  It  has  occurred 
during  yawning,  violent  vomiting,  etc.  In  more 
than  one  case  the  accident  happened  while  a 
dentist  was  taking  a  cast  of  the  mouth.  Hamilton 
quotes  a  bilateral  dislocation  in  a  woman  during 
the  violent  gesticulations  incident  to  the  pursuit 
of  scolding  her  husband.  When  the  mouth  is 
widely  opened,  the  condyles,  together  with  the 
interarticular  fibro-cartilage,  glide  forward.  The 
fibro-cartilage  extends  as  far  as  the  anterior  edge 
of  the  eminentia  articularis,  which  is  coated  with 
cartilage  to  receive  it.  The  condyle  never  reaches 
quite  so  far  as  the  summit  of  that  eminence.  All 
parts  of  the  capsule  save  the  anterior  are  rendered 
tense.  The  coronoid  process  is  much  depressed. 
Now  if  the  external  pterygoid  muscle  (the  muscle 
mainly  answerable  for  the  luxation)  contract  vigor- 
ously, the  condyle  is  soon  drawn  over  the  eminence 
into  the  zygomatic  fossa,  the  interarticular  cartil- 


Chap.  VII]  THE    FACE  133 

age  remaining  behind.  On  reaching  its  new  posi- 
tion it  is  immediately  drawn  up  by  the  temporal, 
internal  pterygoid,  and  masseter  muscles,  and  is 
thereby  more  or  less  fixed.  A  specimen  in  the 
Musee  Dupuytren  shows  that  the  fixity  of  the  lux- 
ated jaw  may  sometimes  depend  upon  the  catch- 
ing of  the  apex  of  the  coronoid  process  against 
the  malar  bone. 

Subluxation  of  the  jaw  is  a  name  given  to  a 
slight  and  quite  incomplete  dislocation  of  the  jaw 
not  unf  requently  met  with  in  delicate  women.  It  is 
due  to  a  displacement  of  the  interarticular  cartil- 
age, and  can  be  cured  by  exposing  the  cartilage  and 
attaching  it  by  suture  to  the  fibrous  structures 
around  the  joint  (Annandale). 

Excision  of  tlie  inferior  maxilla. — Con- 
siderable portions  of  the  lower  jaw  can  be  excised 
through  the  mouth  without  external  wound.  In  ex- 
cising one  entire  half  of  the  maxilla,  a  cut  is  made 
vertically  through  the  lower  lip  down  to  the  point 
of  the  chin,  and  is  then  continued  back  along  the 
inferior  border  of  the  jaw,  so  as  to  end  near  the 
lobule  of  the  ear,  after  having  been  carried  verti- 
cally upwards  in  the  line  of  the  posterior  border 
of  the  ramus.  The  soft  parts  divided  may  be  con- 
sidered under  three  heads  :  Those  concerned  (1)  in 
the  first  incision  ;  (2)  in  clearing  the  outer  surface 
of  the  bone  ;  (3)  in  clearing  the  inner  surface  of  the 
bone. 

1.  (a)  In  the  anterior  vertical  cut:  Skin,  etc., 
orbicularis  oris,  inferior  coronary  and  inferior 
labial  vessels,  branches  of  submental  artery,  leva- 
tor menti,  mental  vessels  and  nerve,  some  radicles 
of  anterior  jugular  vein,  (b)  In  the  horizontal  cut : 
Skin,  etc.,  platysma,  branches  of  superficial  cer- 
vical nerve,  branches  of  supramaxillary  part  of 
facial  nerve,  facial  artery  and  vein  at  edge  of  mas- 
seter, and  inframaxillary  branch  of  facial  nerve 
(not  necessarily  divided),  (c)  The  posterior  verti- 
cal incision  would  not  go  down  to  the  bone,  and 
would  merely  expose  the  surface  of  the  parotid 
gland  and  part  of  posterior  border  of  masseter  muscle. 


134  SURGICAL    APPLIED    ANATOMY       [Part  I 

2.  In  clearing  the  outer  surface  the  following 
parts  are  dissected  back  :  Levator  menti,  the  two 
depressor  muscles,  buccinator,  masseter  (crossed 
by  part  of  parotid  gland,  transverse  facial  vessels, 
facial  nerve,  and  Stenson's  duct),  masseteric  ves- 
sels and  nerve,  temporal  muscle. 

3.  In  clearing  the  inner  surface  :  Digastric, 
genio  hyoid,  genio-hyo-glossus,  and  mylo-hyoid 
muscles,  a  few  fibres  of  superior  constrictor,  in- 
ternal pterygoid  muscle,  inferior  dental  artery 
and  nerve,  mylo-hyoid  vessels  and  nerve,  internal 
lateral  ligament,  rest  of  insertion  of  temporal 
muscle,  mucous  membrane. 

Parts  in  risk  of  being  damaged. — The  facial 
nerve,  if  the  posterior  vertical  incision  be  carried 
too  high  up.  The  internal  maxillary  artery, 
temporo-maxillary  vein,  auriculo-temporal  nerve 
(structures  all  closely  related  to  the  jaw  condyle), 
external  carotid  artery,  lingual  nerve,  the  parotid, 
submaxillary,  and  sublingual  glands.  After  sub- 
periosteal resection  the  entire  bone  has  been  re- 
produced. 

Deformities. — The  lower  jaw  may  be  entirely 
absent,  or  of  dwarfed  dimensions,  or  incompletely 
formed.  These  conditions  are  congenital,  and 
depend  upon  the  defective  development  of  the 
mandibular  or  first  visceral  arch,  out  of  which 
the  lower  jaw  is  formed  (Fig.  24,  p.  114).  They 
are  often  associated  with  branchial  fistulse,  super- 
numerary ears,  macrostoma,  and  like  congenital 
malformations. 

With  regard  to  the  nerves  connected  with  the 
jaws,  little  need  be  said.  The  upper  teeth  are 
supplied  by  the  second  division  of  the  fifth,  the 
lower  by  the  third.  Some  remarkable  nerve  dis- 
turbances have  followed,  by  reflex  action,  upon 
irritation  of  the  dental  nerves.  Thus  cases  of  stra- 
bismus, temporary  blindness,  and  wry-neck  have 
been  reported  as  due  to  the  irritation  of  carious 
teeth.  Hilton  gives  the  case  of  a  man  who  was 
much  troubled  by  a  carious  tooth  in  the  lower  jaw 
(supplied  by  the  third  division  of  the  fifth),   and 


Chap.  VII]  THE    FA.CE  135 

who  developed  a  patch  of  grey  hair  over  the  region 
supplied  by  the  auriculo-temporal  nerve  (a  branch 
also  of  the  third  division). 

Caries  of  the  teeth  is  frequently  associated  with 
areas  of  hyperesthesia  on  the  side  of  the  face  and 
neck.  The  explanation  of  the  reflection  of  pain 
set  up  by  dental  caries,  to  certain  areas  of  skin, 
must  be  sought  for  in  a  close  association  of  the 
central  nerve  nuclei,  in  which  the  cutaneous  and 
dental  nerves  terminate.  Disease  of  the  peridental 
membrane  does  not  give  rise  to  referred  pains 
(Head). 

The  muscles  of  mastication  are  often  at- 
tacked by  spasm.  When  the  spasm  is  clonic  the 
chattering  of  the  teeth,  that  is  so  conspicuous  a 
feature  in  rigor,  is  produced.  When  the  spasm  is 
tonic  the  mouth  is  rigidly  closed,  and  the  condi- 
tion known  as  trismus,  or  lockjaw,  is  produced. 
Trismus  is  amongst  the  first  symptoms  of  tetanus. 
It  is  also  very  apt  to  be  produced  by  irrita- 
tion of  any  of  the  sensory  branches  of  the  third 
division  of  the  fifth,  since  the  motor  nerve 
supply  of  the  muscles  themselves  is  derived 
from  that  trunk.  Thus  trismus  is  very  common 
in  caries  of  the  lower  teeth,  and  during  the 
"  cutting  "  of  the  lower  wisdom  tooth.  It  is 
much  less  common  in  affections  of  the  upper 
set  of  teeth,  since  they  are  supplied  by  a  more 
remote  division  of  the  fifth  nerve.  If  the  motor 
root  of  the  third  division  of  the  fifth  nerve 
be  cut  in  excising  the  Gasserian  ganglion,  paralysis 
and  atrophy  overtake  the  muscles  of  mastication 
of  the  corresponding  side.  The  muscles  of  the 
sound  side,  however,  are  still  able  to  carry  on  the 
necessary  movements  of  the  jaw  concerned  in 
speech  and  mastication. 

Teeth. — As  a  test  of  age  the  following  periods 
for  the  eruption  of  teeth  are  given  by  Mr.  C. 
Tomes  :  Temporary  teeth :  Lower  central  incisors, 
six  to  nine  months ;  upper  incisors,  ten  months ; 
lower  lateral  incisors  and  four  first  molars,  a  few 
months  later  ;   then,   after  a  rest  of  four  or  five 


136  SURGICAL    APPLIED    ANATOMY       [Part  I 

months,  the  canines;  and,  lastly,  the  second 
molars;  the  whole  being  in  place  by  the  end  of  the 
second  year.  Permanent  teeth:  First  molars,  sixth 
or  seventh  year ;  next  in  order  the  lower  central 
incisors,  then  the  upper  central  incisors,  and  a 
little  later  the  laterals,  the  eighth  year  ;  first  bicus- 
pids, ninth  or  tenth  year;  second  bicuspids  and 
canines,  about  the  eleventh  year,  the  lower  preced- 
ing the  upper;  the  second  molars,  the  twelfth  or 
thirteenth  year ;  the  wisdom  teeth,  eighteen  to 
twenty-live  or  later. 

An  alveolar  abscess  is  formed  about  the 
fang  of  a  tooth.  In  the  case  of  single-f anged  teeth 
the  pus  may  escape  along  the  groove  of  the  fang. 
With  other  teeth  the  pus  tends  to  pierce  the  al- 
veolus. If  the  point  of  the  fang  is  within  the  re- 
flection of  the  mucous  membrane  from  the  gum  to 
the  cheek  the  abscess  will  break  into  the  mouth, 
but  if  the  point  of  the  fang  is  without  that  reflec- 
tion, or  if  the  pus  can  gravitate  without  the  line 
of  reflection,  then  the  pus  may  break  through  the 
cheek.  Alveolar  abscess  of  the  upper  incisors  and 
canines  never  breaks  through  the  cheek.  When 
connected  with  the  upper  molars  it  sometimes 
does.  When  connected  with  any  of  the  lower 
teeth  the  abscess  may  find  its  way  through  the  skin 
of  the  cheek. 

The  upper  wisdom  tooth  is  developed  in  the 
posterior  border  of  the  upper  jaw,  and  the  lower 
wisdom  on  the  inner  aspect  of  the  ascending 
ramus.  They  may  fail  to  come  into  position  or  re- 
main buried.  They  may  give  rise  to  deeply-seated 
and  obscure  abscesses  which  frequently  point  in 
the  neck,  at  some  distance  from  their  seat  of 
origin. 


CHAPTER    VIII 

THE  MOUTH,    TONGUE,  PALATE,  AND 
PHARYNX 

The  lips. — The  principal  tissues  composing  the 
lips  have  the  following  relation  to  one  another, 
proceeding  from  without  inwards:  (1)  Skin;  (2) 
superficial  fascia;  (3)  orbicularis  oris;  (4)  coron- 
ary vessels;  (5)  mucous  glands,  and  (6)  mucous 
membrane.  The  free  border  of  the  lip  is  very  sensi- 
tive, many  of  the  nerves  having  end  bulbs  closely 
resembling  tactile  corpuscles.  The  upper  lip  is 
supplied  with  sensation  by  the  second  division  of 
the  fifth  nerve,  and  the  lower  lip  by  the  third  divi- 
sion. Over  these  labial  nerves  a  crop  of  herpes 
often  appears  (herpes  labialis).  The  free  border  of 
the  lower  lip  is  more  frequently  the  seat  of  epithe- 
lioma than  is  any  other  part  of  the  body ;  its  lym- 
phatic vessels  pass  to  the  submental  and  submaxil- 
lary lymphatic  glands  (Fig.  35,  p.  190).  The  lips 
contain  much  connective  tissue,  and  may  swell 
considerably  when  inflamed,  or  cedematous.  They 
are  very  mobile,  and  are  entirely  free  for  a  con- 
siderable extent  from  bony  attachment  of  any 
kind.  It  follows  that  destructive  inflammations  of 
the  lips,  and  such  losses  of  substance  as  accom- 
pany severe  burns,  produce  much  contraction  and 
deformity  of  the  mouth.  Contracting  cicatrices, 
also,  in  the  vicinity  of  the  mouth  are  apt  to  drag 
upon  the  lips,  everting  them  or  producing  kindred 
distortions.  It  is  fortunate  that  the  laxity  of  the 
tissues    around    the  mouth,  and  the   general    vascu- 

137 


138  SURGICAL    APPLIED    ANATOMY       [Part  I 

larity  of  the  part,  greatly  favour  the  success  of  the 
many  plastic  operations  performed  to  relieve  these 
deformities. 

The  lips  are  very  vascular,  and  are  often  the 
seat  of  nsevi  and  other  vascular  tumours.  The 
coronary  arteries  are  of  large  size,  and  their  pul- 
sations can  generally  be  felt  when  the  lip  is 
pinched  up.  These  vessels  run  beneath  the  orbi- 
cularis oris  muscle,  and  are  consequently  nearer 
to  the  mucous  membrane  than  they  are  to  the  skin. 
When  the  inner  surface  of  the  lip  is  cut  against 
the  teeth,  as  the  result  of  a  blow,  these  arteries 
are  very  apt  to  be  wounded.  As  such  wounds  are 
concealed  from  view,  the  consequent  haemorrhage 
has  sometimes  given  rise  to  an  erroneous  diagnosis. 
Thus,  Mr.  Erichsen  quotes  the  case  of  a  drunken 
man,  the  subject  of  such  a  wound,  who,  having 
swallowed,  and  then  vomited,  the  blood  escaping 
from  a  coronary  artery,  was  for  a  while  supposed 
to  be  suffering  from  an  internal  injury.  As  the 
anastomoses  between  the  arteries  of  the  lip  are 
very  free,  it  is  usually  necessary  to  tie  'both  ends 
of  the  vessel  when  it  has  been  cut  across. 

The  mucous  glands  in  the  submucous  tissue  are 
large  and  numerous.  From  closure  of  the  ducts 
of  these  glands,  and  their  subsequent  distension, 
result  the  "  mucous  cysts "  that  are  so  common 
about  the  lips.  "Hare-lip"  is  noticed  below  in 
connection  with  the  subject  of  cleft  palate. 

The  buccal  cavity. — The  following  points 
may  be  noticed  in  the  examination  of  the  interior 
of  the  mouth.  In  the  floor  of  the  mouth,  on  either 
side  of  the  frsenum  linguae,  can  be  observed  the 
sublingual  papillae  with  the  openings  of  Whar- 
ton's ducts.  The  duct  of  Bartholin  (one  of  the 
ducts  of  the  sublingual  gland)  runs  along  the  last 
part  of  Wharton's  duct,  and  opens  either  with  it 
or  very  near  it.  Wharton's  duct  is  singularly 
indistensible,  and  hence  is  partly  explained  the 
intense  pain  usually  observed  when  that  duct  is 
obstructed  by  a  calculus.  The  proximity  of  this 
duct  to  the  lingual  nerve  may  serve  also  to  ac- 


Chap.  Villi 


THE    MOUTH 


139 


count  for  the  pain  in  some  cases.  The  submaxil- 
lary gland  can  be  made  out  through  the  mucous 
membrane  at  a  point  a  little  in  front  of  the  angle 
of  the  jaw,  especially  when  the  gland  is  pressed 
up  from  the  outside.  On  the  floor  of  the  mouth, 
between  the  alveolus  and  the  anterior  part  of  the 
tongue,  is  a  well-marked  ridge  of  mucous  mem- 
brane, that  is  directed  obliquely  forwards  and  in- 
wards to  the  sublingual  papilla  near  the  frsenum 
(Fig.  29).  It  indicates  the  position  of  the  sub- 
lingual gland,  and  also,  so  far  as  it  goes,  the  line 
of  Wharton's  duct  and  the  lingual  nerve.  These 
structures,  with  the  sublingual  artery,  lie  beneath 


CErti071V0-Ci.0SSUt 


UP.  U/tCUAUS 
l/lMjflCUALIS 

AIyO-QlOSSUS 
Li/igual  Artery 
Subungual  Cla/io 
Sublingual  Arter* 


CEflKWIVOID 
/1yLO-/1v0lO 

Digastric 


Fig. 


29. — Section  across  tongue  and  mandible  to  show  the  position  of 
the  sublingual  gland  and  lingual  artery.     (After  Poirier.) 


the  mucous  membrane  between  the  gland  and  the 
side  of  the  tongue.  The  ducts  of  the  sublingual 
gland,  some  ten  to  twenty  in  number,  open  into 
the  mouth  along  the  ridge  of  mucous  membrane 
just  referred  to.  Ranula,  a  cystic  tumour  filled 
with  mucous  contents,  is  often  met  with  over  the 
site  of  the  sublingual  gland,  and  is  due  to  the  dila- 
tation of  one  of  the  gland  ducts  that  has  become  ob- 
structed, or  to  an  occluded  mucous  follicle.  The 
mucous  membrane  of  the  floor  of  the  mouth,  as  it 
passes  forward  to  be  reflected  on  to  the  gums,  is 
attached  near  to  the  upper  border  of  the  jaw  (Fig. 
29).  Here  also  are  situated  some  mucous  glands 
which  may  become  cystic.  The  genio-hyo-glossus 
is  attached  near  the  lower  border.     Between  these 


140  SURGICAL    APPLIED    ANATOMY       [Part  I 

two  parts  (the  mucous  membrane  and  the  muscle) 
there  is,  according  to  Tillaux,  a  small  space  lined 
with  squamous  epithelium.  To  this  cavity  the 
name  of  the  sublingual  bursa  mucos'a  is  given. 
It  is  constricted  in  its  centre  by  the  frsenum 
linguae,  and  is  said  to  be  the  seat  of  mischief  in 
"  acute  ranula.'; 

When  the  mouth  is  widely  opened  the  pterygo- 
maxillary  ligament  can  be  readily  seen  and  felt  be- 
neath the  mucous  membrane.  It  appears  as  a  pro- 
minent fold  running  obliquely  downwards]  behind 
the  last  molar  teeth.  A  little  below  and  in  front 
of  the  attachment  of  this  ligament  to  the  lower 
jaw,  the  gustatory  nerve  can  be  felt  as  it  lies  close 
to  the  bone  just  below  the  last  molar.  This  nerve 
is  sometimes  divided  for  the  relief  of  pain  in  cases 
of  carcinoma  of  the  tongue.  Mr.  Moore's  method 
of  dividing  it  is  as  follows :  "  He  cuts  the  nerve 
about  \  an  inch  from  the  last  molar  tooth,  at  a 
point  where  it  crosses  an  imaginary  line  drawn 
from  that  tooth  to  the  angle  of  the  jaw.  He  enters 
the  point  of  the  knife  nearly  f  of  an  inch  behind 
and  below  the  tooth,  presses  it  down  to  the  bone, 
and  cuts  towards  the  tooth "  (Stimson).  This 
nerve,  as  it  lies  against  the  bone,  has  been  crushed 
by  the  slipping  of  the  forceps  in  clumsy  extraction 
of  the  lower  molar  teeth. 

The  coronoid  process  of  the  lower  jaw  can  be 
easily  felt  through  the  mouth,  and  is  especially  dis- 
tinct when  that  bone  is  dislocated.  It  may  be 
noted  that  a  fair  space  exists  between  the  last 
molar  tooth  and  the  ramus  of  the  inferior  maxilla, 
through  which  a  patient  may  be  fed  by  a  tube  in 
cases  of  trismus  or  ankylosis  of  the  jaw. 

A  congenital  dermoid  cyst  is  sometimes  found 
in  the  floor  of  the  mouth  between  the  tongue  and 
the  lower  jaw.  Such  cysts  are  supposed  to  be  due 
to  the  imperfect  closure  of  the  first  visceral  or 
post-mandibular  cleft. 

The  gums  are  dense,  firm,  and  very  vascular. 
In  the  bleeding  that  follows  the  extraction  of 
teeth  much  of  the  blood  is  supplied  by  them.     The 


Chap.  VIII]  THE    MOUTH  141 

gums  are  particularly  affected  in  mercurial  poison- 
ing, and  are  also  especially  involved  in  scurvy. 
In  chronic  lead-poisonmg  a  blue  line  often  appears 
along  their  margins.  This  is  due  to  a  deposit  of 
lead  sulphide  in  the  gum  tissues,  which  is  thus  de- 
rived :  Food  debris  collected  about  the  teeth  in 
decomposing  produces  hydrogen  sulphide,  which, 
acting  upon  the  lead  circulating  in  the  blood,  pro- 
duces the  deposit.  The  blue  line,  therefore,  is  said 
not  to  occur  in  those  who  keep  the  teeth  clean. 

The  tongue.— On  the  under  surface  of  tihe 
tongue,  less  than  h  an  inch  from  the  fraenum,  the 
end  of  the  ranine  vein  can  be  seen  beneath  the 
mucous  membrane.  Two  elevated  and  fringed 
lines  of  mucous  membrane  may  be  seen  on  the 
under  surface  of  the  organ  converging  towards  its 
tip.  Thev^  indicate  the  position  of  the  ranine 
artery,  which  is  more  deeply  placed  than  the  vein, 
close  to  which  it  lies.  It  is  extremely  rare  for  the 
tongue  to  be  the  seat  of  congenital  defect.  The 
author  of  the  able  monograph  on  the  tongue  iD 
Holmes's  "  System  of  Surgery  ''  has  discovered 
only  one  instance  of  congenital  absence  of  the 
organ.  Fournier  gives  a  case  where  the  tongue 
was  so  much  longer  than  usual  that  the  chest  could 
be  touched  with  its  tip  while  the  head  was  held 
erect. 

In  rare  cases  the  frsenum  linguae  may  be 
abnormally  short,  constituting  the  condition  known 
as  "tongue-tie,"  which  is  really  a  very  uncommon 
affection.  The  fraenum  when  divided  should  be 
cut  as  near  the  jaw  as  possible,  so  as  to  avoid 
the  ranine  vessels.  Division  of  these  vessels  in 
relieving  tongue-tie  has  led  to  fatal  haemorrhage, 
the  bleeding  being  encouraged  by  the  efforts  of 
sucking.  "If  the  frsenum  and  subjacent  muscle 
fibres  be  too  freely  divided,  energetic  sucking  on 
the  part  of  a  hungry  child  may  tear  the  wound  of 
these  very  lax  tissues  farther  and  farther  open, 
until  the  tongue,  having  lost  all  its  anterior  sup- 
port, turns  over  into  the  pharynx,  and  is  firmly 
embraced  by  the  muscles  of  deglutition,  which  force 


142  SUKGICAL    APPLIED    ANATOMY       [Part  I 

it  down  upon  the  epiglottis,  and  the  latter  upon  the 
larynx,  until  suffocation  is  produced  *;  (Holmes's 
"  System  of  Surgery,"  vol.  ii).  In  complete  anaes- 
thesia, as  in  that  produced  by  chloroform,  when  all 
the  muscular  attachments  of  the  tongue  are  re- 
laxed, the  organ  is  apt  to  fall  back  and  to  press 
down  the  epiglottis,   so  causing  suffocation. 

The  tongue  is  firm  and  dense,  but  contains, 
nevertheless,  a  sufficient  amount  of  connective 
tissue  to  cause  it  to  swell  greatly  when  inflamed. 
The  surface  epithelium  is  thick,  and  in  chronic 
superficial  inflammation  of  the  organ  it  often  be- 
comes heaped  up,  forming  dense  opaque  layers, 
ichthyosis  linguae,  plaques  des  fumeurs,  leucoma, 
etc.  From  the  mucous  glands,  situated  chiefly  be- 
neath the  mucous  membrane  near  the  base  of  the 
tongue,  the  mucous  cysts  are  developed  that  are 
sometimes  met  with  in  this  part. 

The  tongue  is  very  vascular,  and  is  in  conse- 
quence often  the  seat  of  naevoid  growths.  Its  main 
supply  is  from  the  lingual  artery.  This  vessel  ap- 
proaches the  organ  from  the  under  surface,  and  as 
cancer  usually  shows  a  tendency  to  spread  towards 
the  best  blood  supply,  it  is  to  be  noticed  that  car- 
cinoma of  the  tongue  nearly  always  tends  to  spreac? 
towards  the  deep  attachment  of  the  member.  At 
the  same  time  it  must  be  observed  that  the  main 
lymphatics  follow  the  same  course  as  the  main 
blood-vessels.  The  vascularity  of  the  tongue  is 
the  great  bar  to  its  easy  removal,  haemorrhage 
being  the  complication  most  to  be  dreaded  in  such 
operations. 

The  tongue  is  well  supplied  with  nerves,  that 
endue  it  not  only  with  the  special  sense  of  taste, 
but  also  with  common  sensation.  According  to 
Weber's  experiments,  tactile  sensibility  is  more 
acute  on  the  tip  of  the  tongue  than  it  is  on  any 
part  of  the  surface  of  the  body.  It  should  be  borne 
in  mind  that  the  lingual  nerve  supplies  the  fore 
part  and  sides  of  the  tongue  for  two-thirds  of  its 
surface,  whii'e  the  glossopharyngeal  nerve  sun- 
plies  the  mucous  membrane  at  its  base,  and  especi- 


Chap.  VIII]  THE    MOUTH  143 

ally  the  papillae  vallatae.  In  painful  affections, 
situated  in  the  area  supplied  by  the  lingual  nerve, 
the  patient  is  often  troubled  with  severe  pains 
deep  in  the  region  of  the  meatus  of  the  ear,  and 
an  area  of  skin  from  the  ear  along  the  lower  bor- 
der of  the  jaw  may  be  tender  (Head).  The  anterior 
two-thirds  of  the  tongue  is  a  derivative  of  the  man- 
dibular arch,  which  also  forms  the  anterior  boun- 
dary of  the  meatus.  Hence  the  nerve  supply  of 
the  anterior  part  of  the  tongue  from  the  third  divi- 
sion of  the  fifth  nerve  and  the  reference  of  pain  to 
its  cutaneous  termination.  The  posterior  third  of 
the  tongue  is  derived  from  the  second  (hyoid)  and 
third  visceral  arches  and  is  associated  with  tender 
areas  in  the  skin  over  the  larynx  (Head).  Spas- 
modic contraction  of  the  masticatory  muscles  is 
sometimes  found  to  accompany  painful  lingual  ul- 
cers when  involving  the  region  of  the  gustatory 
nerve.  There  would  seem  to  be  but  little  connec- 
tion between  an  abscess  over  the  occipital  region 
and  wasting  of  one  half  of  the  tongue.  But  Sir 
James  Paget  reports  the  following  case:  "A  man 
received  an  injury  to  the  back  of  his  head  that  was 
apparently  not  severe.  In  time  the  right  half  of 
the  tongue  began  to  waste,  and  continued  to  waste 
until  it  was  less  than  half  the  size  of  the  unaltered 
side.  An  abscess  formed  over  the  occiput,  from 
which  fragments  of  the  lower  part  of  the  occipital 
bone  were  removed.  After  the  removal  of  all  the 
dead  bone  the  tongue  began  to  recover,  and  in  one 
month  had  nearly  regained  its  normal  aspect." 
Here  the  atrophy  was  due  to  wasting  of  the  lin- 
gual muscles  produced  by  pressure  upon  the  hypo- 
glossal nerve,  which  leaves  the  skull  through  the 
anterior  condyloid  foramen  in  the  occipital  bone. 
The  case  illustrates  the  importance  of  remember- 
ing even  small  foramina,  and  the  structures  they 
transmit. 

The  tongue  contains  much  lymphoid  tissue,  a 
considerable  part  of  which  (the  lingual  tonsil)  is 
massed  under  the  mucous  membrane  at  the  pos- 
terior part  of  the  organ.  Hypertrophy  of  this  tissue 


144  SURGICAL    APPLIED    ANATOMY       [Part  I 

may  lead  to  troublesome  symptoms  by  interference 
with  the  proper  action  of  the  epiglottis.  The  lin- 
gual and  pharyngeal  adenoid  tissue,  with  the  ton- 
sils proper,  form  a  complete  ring  of  lymphoid 
tissue  round  the  isthmus  of  the  fauces. 

The   lymphatics   of   the   tongue  are   large   and 
numerous,  and  offer  a  free  channel  for  the  dissem- 
ination of  cancerous  emboli.     They  are  arranged 
in  two  systems  :    (1)  Superficial,   forming  an  ex- 
tremely  rich   plexus  in  the   submucous  tissue   on 
the  dorsum  and  sides  of  the  tongue;  (2)  deep,  ar- 
ranged  as   a  network  in   the  musculature   of  the 
tongue.  These  two  systems  are  in  free  communica- 
tion ;    Cheatle    found    that    the    genio-hyo-glossus 
muscle  was  a  common  site  of  secondary  deposit  in 
cases  of  cancer  of  the  tongue.     The  lymph  from 
these  two  systems  is  carried  off  by  the  following 
sets  of  efferent  vessels :   (1)  the  marginal  or  lateral 
vessels,  which  leave  the  submucous  plexus  on  the 
side   of  the  tongue   and   pass  partly  to  the   sub- 
maxillary group  of  glands  and  partly  to  the  upper 
deep  cervical  group ;  (2)  the  central  vessels,  which 
form   between   the   two   genio-hyo-glossus   muscles 
and  end  in  the  upper  deep  cervical  glands ;  (3)  the 
apical  vessels,  which  end  in  the  submental  gland 
and   in   the    upper    deep   cervical ;    (4)    the   basal 
vessels    from   the    posterior    third   of   the   tongue 
which    terminate    in     the     upper     deep    cervical 
group.*      The    tongue    is    one    of    the    commonest 
sites  for  cancer,  and  the  disease  commonly  affects 
the    anterior    two-thirds,    which    is   derived    from 
the  mandibular  arch.     So  is  the  lower  lip,  which 
also    is    a    common    site.      Cancer    spreads    along 
the    lymphatic    vessels,     which  >  for    the     greater 
part  accompany  the  lingual  vein  and  artery  and 
pour  their  lymph  and  emboli  in  the  upper  deep 
cervical  glands,  behind  and  below  the  angle  of  the 
jaw.     The  normal  paths  are  soon  choked,  and  the 
lymph  has  to  follow  circuitous  by-paths.    The  lym- 
phatic glands  over   the   submaxillary   gland,    the 

*  For  a  full  account  of  the  lymphatics  see  Poirier's  "Lymphatics," 
translated  by  Cecil  Leaf,  1903. 


Chap.  VIII]  THE    MOUTH  145 

lymphoid  tissue  in  that  gland  and  in  the  sublin- 
gual, become  the  seats  of  secondary  deposit.  The 
submental  gland  may  also  be  affected. 

In  the  strange  congenital  affection  known  as 
macroglossia  the  tongue  becomes  much  enlarged, 
and  in  some  cases  may  attain  prodigious  dimen- 
sions. The  enlargement  is  primarily  due  to  the 
greatly  dilated  condition  of  the  lymphatic  chan- 
nels of  the  organ  (hence  the  name,  lymphangioma 
cavernosum,  proposed  by  Virchow),  and  to  an  in- 
creased development  of  lymph  tissue  throughout 
the  part.  The  portion  most  conspicuously  affected 
is  the  base  of  the  tongue,  where  the  lymphatics 
are  usually  the  most  numerous. 

A  dermoid  cyst  may  be  met  with  on  the  under 
surface  of  the  tongue.  It  is  usually  placed  in  the 
median  line  between  the  genio-hyo-glossi  muscles. 
Such  cysts  are  probably  due  to  some  infolding  of 
the  integumental  layer  during  development. 

Accessory  glands  about  the  tongue.— 
Streckeisen  states  that  accessory  glands,  belong- 
ing to  the  thyroid  body,  are  frequently  found  in 
the  vicinity  of  the  hyoid  bone.  They  are  also 
found  in  the  basal  part  of  the  tongue,  near  the 
foramen  caecum  (Makins).  Some  may  be  super- 
ficial to  the  mylo-hyoid  muscle,  others  may  be  just 
above  the  hyoid  bone,  and  others  in  the  hollow  of 
that  bone.  Cysts  lined  with  ciliated  epithelium 
may  sometimes  be  found  in  the  same  situations. 
All  these  structures  are  the  remains  of  the  neck 
of  the  central  diverticulum  which  is  protruded 
from  the  ventral  wall  of  the  pharynx  in  the  em- 
bryo, and  from  which  the  isthmus  and  pyramidal 
parts  of  the  thyroid  gland  are  formed.  The  fora- 
men ececum  on  the  tongue  indicates  the  spot  where 
this  diverticulum  leaves  the  pharynx.  Ducts  lined 
with  epithelium  have  been  found  leading  from  the 
foramen  csecum  to  accessory  glands  about  the  hyoid 
bone.  It  is  probably  from  these  glandular  and 
epithelial  collections  about  the  hyoid  bone  that  cer- 
tain deep-seated  forms  of  cancer  of  the  neck  are 
developed.     Some  of  these  take  the  form  of  malig- 

K 


146  SUKGICAL    APPLIED    ANATOMY       [Part  I 

nant   cysts    described    by   the    author   (Path.    Soc. 
Trans.,  1886). 

Excision.  —  Many  different  methods  have  been 
adopted  for  the  removal  of  the  entire  tongue.  It 
has  been  removed  through  the  mouth  by  the  ecra- 
seur  or  the  scissors,  the  latter  operation  being  per- 
formed with  or  without  previous  ligature  of  the 
lingual  arteries  in  the  neck.  It  is  difficult,  however, 
to  fully  expose  the  deeper  attachments  of  the  organ 
through  the  comparatively  small  orifice  of  the 
mouth.  To  obtain  more  room  the  cheek  has  been 
slit  up  in  one  procedure,  while  the  lower  lip  and 
symphysis  of  the  lower  jaw  have  been  divided  in 
another. 

In  another  series  of  operations  the  tongue  has 
been  reached,  or  the  organ  has  been  fully  exposed, 
by  an  incision  made  between  the  hyoid  bone  and 
the  inferior  maxilla.  More  recently  Kocher  has 
exposed  the  tongue  from  the  neck,  and  has  reached 
it  by  an  incision  commencing  near  the  ear  and  fol- 
lowing the  anterior  border  of  the  sterno-mastoid 
muscle  as  far  as  the  hyoid  bone,  whence  it  turns 
upwards  along  the  anterior  belly  of  the  digastric 
muscle.  This  method  allows  free  removal  of  the 
upper  deep  cervical  glands,  the  lymphatic  glands, 
and  the  tissue  over  and  in  the  submaxillary  and 
sublingual  glands  which  form  the  seats  of  second- 
ary cancerous  deposits. 

In  the  removal  of  the  entire  organ,  the  follow- 
ing parts  are  of  necessity  divided:  The  frsenum, 
the  mucous  membrane  along  the  sides  of  the 
tongue,  the  glosso-epiglottic  folds,  the  genio-hyo- 
glossus,  hyo-glossus,  stylo-glossus,  palato-glossus 
muscles,  the  few  fibres  of  the  superior  and  inferior 
linguales  muscles  that  are  attached  to  the  hyoid 
bone,  the  terminal  branches  of  the  gustatory, 
glosso-pharyngeal,  and  hypoglossal  nerves,  the 
lingual  vessels,  and,  at  the  side  of  the  tongue  near 
its  base,  some  branches  of  the  ascending  pharyn- 
geal artery,  and  of  the  tonsillar  branch  of  the 
facial  artery. 

Bleeding  from  the  stump  of  the  tongue,  after 


Chap.  VIII] 


THE    PALATE 


147 


removal,  can  be  instantly  and  almost  entirely  ar- 
rested by  pressing  the  root  of  the  tongue  forwards 
with  two  fingers  passed  down  behind  it  into  the 
pharynx.  The  lingual  arteries  as  they  lie  divided 
in  the  floor  of  the  mouth  are  difficult  to  secure. 
They  are  embedded  in  muscle,  and  appear  to  be 
peculiarly  brittle. 

When  both  Unguals  have  been  ligatured  in  the 
neck  (through  the  hyo-glossus  muscle)  before  re- 
moving the  tongue,  bleeding  still  takes  place  from 
the   dorsalis   linguae   branches   of   the   lingual   and 


Fig.  30. — Illustrating  the  relationship  of  the  lateral  incisor  tooth  to  the 

palatal  cleft. 

a,  Normal  hard  palate.    The  premaxilla  is  stii>plecT ;  the  lateral  incisor  occurs  in 

the  suture  between  it  and  the  maxilla. 
is,  Double  cleft  Of  palate,  the  lateral  incisor  being  situated  on  the  preniaxilla  to 

the  inner  side  of  the  cleft.    The  septum  of  the  nose  is  exposed  in  the  cleft 

between  the  maxillary  bones, 
c,  Double  cleft  palate,  the  lateral  incisor  being  situated  on  the  maxilla  to  the  outer 

side  of  the  cleft. 

from  small  branches  of  the  ascending  pharyngeal 
and  facial  arteries. 

The  palate.  —  The  arch  of  the  hard  palate 
varies  in  height  and  shape  in  different  individuals, 
and  it  has  been  said  that  the  arch  is  particularly 
narrow  and  high  in  congenital  idiots.  The  outline 
of  this  arch  is  of  some  moment  in  operations  upon 
the  palate. 

Cleft  palate.  —  In  order  to  understand  the 
various  forms  of  cleft  which  occur  in  the  palate 
and  upper  lip,  it  is  necessary  to  review  briefly  the 
development  of  these  parts  ;  for  all  forms  of  cleft 
palate  and  "  hare-lip  '  are  due  to  an  incomplete 
fusion  of  parts.     In  Fig.  30,  a,  the  bony  palate  at 


148  SURGICAL    APPLIED    ANATOMY       [Part  I 

birth  is  shown  to  be  made  up  of  three  elements,  (1) 
the  premaxillary,  carrying  the  four  incisor  teeth, 
(2)  the  right  maxillary,  (3)  the  left  maxillary,  bear- 
ing the  right  and  left  canine  and  milk  molars. 
These  three  parts  are  different  in  origin  :  the  pre- 
maxillary part  is  developed  in  the  mesial  nasal 
process  (Fig.  24,  p.  114) ;  the  maxillary  parts  from 
the  right  and  left  maxillary  processes.  Fusion 
of  the  various  elements  to  form  the  palate  com- 
mences anteriorly  and  proceeds  backwards.  In 
the  posterior  two-thirds  of  the  palate  the  maxillary 
processes  fuse  with  each  other  in  the  median  line, 
but  in  the  anterior  third  they  unite  with  the  pre- 
maxillary part.  Thus  the  line  of  fusion  is 
T-shaped,  the  premaxillary  part  occupying  the 
fork.  In  the  majority  of  cases  the  cleft  occurs  in 
the  position  of  the  main  stem  of  the  T,  or  it  may 
affect  only  the  soft  palate ;  or  it  may  extend 
forwards  to  the  alveolus  on  one  side  or  on  both,  as 
is  shown  in  Fig.  30,  b,  c.  The  lateral  incisor  is 
developed  in  the  groove  between  the  premaxillary 
and  maxillary  elements;  if  the  condition  of  cleft 
palate  occurs,  the  developmental  elements  separate 
as  growth  proceeds ;  the  bud  of  the  lateral  incisor 
may  adhere  to  either  side  of  the  cleft  thus  formed ; 
hence  in  some  cases  this  incisor  is  found  on  the 
premaxillary  process;  in  others,  in  the  maxillary 
(see  Fig.  30,  b,  c).  Each  premaxilla  may  show 
two  centres  of  ossification,  but  the  cleft  is  not,  as 
is  so  often  said,  the  result  of  the  failure  of  union 
of  two  centres  of  ossification,  but  is  due  to  the 
separation  of  the  developmental  parts  of  the 
palate.  As  growth  goes  on,  the  cleft  becomes 
wider. 

The  upper  lip  is  developed  from  the  same  three 
elements  as  the  palate  (Fig.  24,  p.  114) ;  if  the 
palatal  cleft  extends  to  the  alveolus  the  lip  is  also 
affected,  but  a  cleft  on  one  or  both  sides  of  the 
lip  may  occur  without  a  cleft  of  the  palate.  The 
premaxillary  or  median  element  of  the  lip  is  also 
bilateral,  but  it  is  extremely  rare  to  find  a  per- 
sistent separation  of  its  two  parts.     In  cases  of 


Chap.  VIII]  THE    PALATE  149 

double  hare-lip  one  sees  occasionally  two  papillae 
on  the  lower  lip,  fitting  into  the  clefts  in  the  upper 
when  the  lips  are  in  apposition. 

The  mucous  membrane  covering  the  hard 
palate  is  peculiar  in  that  it  is  practically  one 
with  the  periosteum  covering  the  bones ;  and, 
therefore,  in  dissecting  up  this  membrane  the  bone 
is  bared,  as  the  mucous  membrane  and  the  perios- 
teum cannot  be  separated.  The  membrane  is  thin 
in  the  middle  line,  but  is  much  thicker  at  the  sides 
near  the  alveoli,  the  increased  thickness  depend- 
ing mainly  upon  the  introduction  of  a  number 
of  mucous  glands  beneath  the  surface  layers,  such 
glands  being  absent  in  the  middle  line.  The 
density  and  toughness  of  the  soft  covering  of  the 
hard  palate  render  it  very  easy  to  manipulate 
when  dissected  up  in  the  form  of  flaps,  as  in  the 
operation  for  cleft  palate. 

The  main  blood  supply  of  thp.  houps  of  ^  flip. 
hard  palate  and  of  its  mucous  covering  is  derived 
from  the  descending  palatine  branch  of  the  inter- 
nal maxillary  artery.  This  vessel,  which  is 
practically  the  only  vessel  of  the  hard  palate, 
emerges  from  the  posterior  palatine  canal  near 
the  junction  of  the  hard  palate  with  the  soft,  and 
close  to  the  inner  side  of  the  last  molar  tooth. 
The  vessel  runs  forwards  and  inwards,  to  end 
at  the  anterior  palatine  canal.  Its  pulsations  on 
the  palate  can  often  be  distinctly  felt.  In  dis- 
secting up  muco-periosteal  flaps  from  the  hard 
palate,  it  is  most  important  to  make  the  incision 
in  the  mucous  membrane  close  to,  and  parallel 
with,  the  alveolus,  so  that  this  artery  may  be  in- 
cluded in  the  flap  and  its  vitality  therefore  not 
be  endangered.  By  such  an  incision,  also,  un- 
necessary bleeding  is  avoided.  In  dissecting  up 
the  flap  it  should  be  remembered  that  the  artery 
runs  much  nearer  to  the  bone  than  to  the  mucous 
surface. 

The  soft  palate  is  of  uniform  thickness,  its 
average  measurement  being  estimated,  at  about  5 
of  an  inch.      When   the   soft   palate   is   cleft,    the 


150 


SURGICAL    APPLIED    ANATOMY       [Part  I 


edges  of  the  fissure  are  approximated  during 
swallowing  by  the  uppermost  fibres  of  the  superior 
constrictor.  This  approximation  may  narrow  the 
cleft  to  one-third  or  one-half  of  its  previous  size. 
The  muscles  that  tend  to  widen  the  cleft  are,  in 
the  main,  the  levator  palati  and  tensor  palati. 
It  is  necessary  that  these  muscles  should  be 
divided  before  attempting  to  close  the  cleft  by 
operation.  The  levator  palati  crosses  the  palate 
obliquely  from  above  downwards  and  inwards  on 
its  way  to  the  middle  line,  lying  nearer  to  the 
posterior  than  the  anterior  surface  of  the  velum. 
The  tensor  palati  turns  round  the  hamular  pro- 
cess,  and  passes  to  the  middle   line  in  a  nearly 

horizontal  direction  (Fig.  31). 
The  hamular  process  can  be 
felt  through  the  soft  palate 
just  behind  and  to  the  inner 
side  of  the  last  upper  molar 
tooth.  There  are  three  prin- 
cipal methods  of  dividing 
these  muscles:  (1)>  Fergus- 
son's  :  A  small  knife,  with 
the  blade  at  right  angles  to 
the  stem,  is  passed  through 
the  cleft,  and  is  made  to 
divide  the  levator  palati  by 
an  incision  on  the  posterior 
aspect  of  the  palate,  trans- 
verse to  the  direction  of  the 
muscle.  The  tensor  is  not 
divided  in  this  procedure. 
(2)  Pollock's  :  A  thin  narrow 
knife,  with  the  cutting  edge 
upwards,  is  introduced  into 
the  soft  palate  a  little  in  front,  and  to  the  inner 
side,  of  the  hamular  process.  The  tendon  of  the 
tensor  muscle  is  above  the  knife,  and  is  cut  as  the 
knife  is  pushed  upwards  and  inwards.  The  knife 
is  inserted  until  its  point  presents  at  the  upper 
part  of  the  cleft.  As  it  is  being  withdrawn,  it  is 
made  to  cut  the  posterior  surface  of  the  velum 


Fig.  31.—  The  muscles  of  the 
soft  palate,  from  behind. 

a,  Levator  palati ;  b,  tensor 
palati ;  c,  hamular  process  ; 
d,  wall  of  pharynx  ;  e,  azy- 
gos  uvulae ;  /,  the  point  of 
entry  of  the  knife  in  Pol- 
lock's operation  ;  above  it  is 
the  line  of  incision  made  on 
withdrawing  the  knife. 


Chap.  VIII]  THE   PHAKYNX  151 

to  a  sufficient  depth  to  divide  the  levator  palati 
(Fig.  31).  (3)  Bryant's  :  Here  the  palate  muscles 
are  divided  by  a  cut  with  the  scissors  that  in- 
volves the  entire  thickness  of  the  velum,  the  cut 
being  at  the  side  of  the  velum,  and  nearly  parallel 
with  the  cleft. 

The  blood  supply  of  the  soft  palate  is  derived 
from  the  descending  palatine  branch  of  the  in- 
ternal maxillary  artery,  the  ascending  pharyn- 
geal artery,  and  the  ascending  palatine  branch 
of  the  facial  artery.  The  latter  vessel  reaches  the 
velum  by  following  the  levator  palati  muscle,  and 
must  be  divided  in  the  section  made  of  this  muscle 
in  the  procedures  just  described. 

The  muscles  oi  the  palate  are  supplied  by 
several  nerves.  The  levator  palati,  azygos  uvulse, 
and  palato-pharyngeus  are  innervated  with  the 
muscles  of  the  pharynx  by  the  spinal  accessory ; 
the  palato-glossus  with  the  muscles  of  the  tongue 
from  the  hypo-glossal,  and  the  tensor  palati  with 
the  tensor  tympani  from  the  third  division  of  the 
fifth  nerve  through  the  otic  ganglion. 

The  pharynx  is  about  five  inches  in  length. 
It  is  much  wider  from  side  to  side  than  from 
before  backwards.  It  is  widest  at  the  level  of  the 
tip  of  the  greater  cornua  of  the  hyoid  bone,  where 
it  measures  about  2  inches.  It  is  narrowest  where 
it  joins  the  gullet  opposite  the  cricoid  cartilage, 
its  diameter  here  being  less  than  f  of  an  inch. 
The  pharynx  is  not  so  large  a  space  as  supposed, 
for  it  must  be  remembered  that  during  life  it  is 
viewed  very  obliquely,  and  erroneous  notions  are 
thus  formed  of  its  antero-posterior  dimensions. 
The  distance  from  the  arch  of  the  teeth  to  the 
commencement  ot  tne  gullet  is  about  6  to  7  innhps^ 

p,     Tnp.a.aurftTTlftnt     that     aVimilrj — Vip     linrnp     |n     mind 

in  extracting  foreign  bodies.  Foreign  bodies 
passed  into  the  pharynx  are  most  apt  to  lodge 
at  the  level  of  the  cricoid  cartilage,  a  point  that, 
in  the  adult,  is  a  little  beyond  the  reach  of 
the  finger.  The  history  of  foreign  bodies  in  the 
pharynx  shows  that  that  cavity  is  very  dilatable, 


152  SURGICAL    APPLIED    ANATOMY       [Part  I 

and  can  accommodate  for  some  time  large  sub- 
stances. Thus,  in  a  case  reported  by  Dr.  Geoghe- 
gan,  a  man  of  60,  who  had  had  for  months  some 
trouble  in  his  throat  for  which  he  could  not 
account,  was  supposed  to  have  cancer.  On  ex- 
amination, however,  a  plate  carrying  five  false 
teeth,  and  presenting  niches  for  five  natural  ones, 
was  found  embedded  in  the  pharynx,  where  it 
had  been  lodged  for  five  months.  The  plate  had 
been  swallowed  during  sleep  {Med.  Press,  1866). 
In  the  Lancet  for  1868  is  an  account  of  a  mutton 
chop  that  became  lodged  in  the  pharynx  of  a 
gluttonous  individual.  The  chop  presented  the 
ordinary  vertebral  segment  of  bone,  together  with 
1\  inch  of  rib,  and  was  "  pretty  well  covered 
with  meat."  Attempts  to  remove  it  failed,  and 
it  was  finally  vomited  up.  Dr.  Hicks  (Lancet, 
1884)  reports  the  case  of  a  woman  who  committed 
suicide  by  cramming  half  a  square  yard  of  coarse 
calico  (belonging  to  her  nightdress)  into  her 
mouth  and  throat. 

The  walls  of  the  pharynx  are  in  relation  with 
the  base  of  the  skull,  and  with  the  upper  six  cer- 
vical vertebrae.  The  arch  of  the  atlas  is  almost 
exactly  on  a  line  with  the"  hard  pa.1a.tp  The  axis 
is  on  a  line  with  the  free  edge  of  the  upper  teeth. 
The  termination  of  the  tmarynx  corresponds  ^o 
the  sixth  cervical  vertebra.  The  upper  vertebrae 
can  be  examined,  as  regards  their  anterior  sur- 
face, from  the  mouth.  When  the  bones  about  the 
pharynx  are  diseased,  the  necrosed  parts  may  be 
discharged  by  that  cavity.  Thus  portions  of  the 
atlas  and  axis  have  been  expelled  by  the  mouth, 
as  also  have  been  some  fragments  of  comparatively 
large  size  thrown  off  by  the  occipital  and  sphenoid 
bones. 

The  mucous  membrane  of  the  pharynx  is  vas- 
cular, and  readily  inflamed;  and  such  inflamma- 
tions are  peculiarly  dangerous,  in  that  they  may 
spread  to  the  lining  membrane  of  the  larynx. 
The  submucous  tissue  of  the  aryteno-epiglottic 
folds  and  of  the  neighbouring  part  of  the  pharynx 


Chap.  VIII]  THE    PHARYNX  153 

is  peculiarly  loose,  and  in  oedematous  conditions 
the  upper  aperture  of  the  larynx  may  be  almost 
closed. 

Much  adenoid  tissue  is  distributed  in  the 
mucous  membrane  of  the  pharynx,  and  it  is  this 
tissue  that  is  the  primary  seat  of  inflammation 
in  scrofulous  pharyngitis.  A  distinct  collection 
of  adenoid  tissue,  stretches  across  the  hinder  wall 
ofthe  pharvnx  hRtwp.en  the  openings  o?  thft  Eus- 
tachian^ tubes.  It  is  known  as  the  pharyngeal 
tonsil.  In  and  near  the  lateral  recess,  just  be- 
hind the  opening  of  the  Eustachian  tube,  the 
lymphoid  tissue  forms  a  thick  layer  or  mass  (Fig. 
22,  p.  101).  This  deposit  of  adenoid  tissue  may 
undergo  hypertrophic  change  and  the  condition 
known  as  "  adenoid  vegetations  ;;  or  "  post-nasal 
growths  ;;  be  produced.  These  growths  may  cause 
deafness,  and  may  block  the  posterior  nares. 
They  need  to  be  removed  by  operation. 

The  tissue  immediately  outside  the  pharyngeal 
walls  is  lax,  and  favours  the  spread  of  effusion. 
Thus,  in  acute  inflammation  of  the  pharynx  the 
effusion  has  been  found  to  extend  along  the  oeso- 
phagus, reaching  the  posterior  mediastinum,  and 
advancing  even  to  the  diaphragm.  In  the  lax 
connective  tissue  between  the  pharynx  and  the 
spine  abscess  is  not  infrequent,  due,  as  a  rule,  to 
caries^  of  the  vertebrae  (postpharyngeal  abscess). 
In  this  connective  tissue,  and  opposite  the  axis, 
is  also  found  a  lymphatic  gland  that  receives 
lymphatics  from  the  nasal  cavity  and  naso- 
pharynx. This  gland  may  prove  the  seat  of  a 
suppuration.  Such  collections  may  so  push  for- 
ward the  posterior  pharyngeal  wall  as  to  depress 
the  soft  palate,  or  may  cause  severe  dyspnoea 
by  interference  with  the  larynx.  The  matter  may 
discharge  itself  through  the  mouth,  or  may  reach 
the  neck  by  passing  behind  the  great  vessels  and 
the  parotid  gland,  presenting  ultimately  beneath 
or  at  one  border  of  the  sterno-mastoid  muscle. 

_  Many  structures  of  importance  are  in  relation 
with  the  lateral  walls  of  the  pharynx,   the  prin- 


154  SURGICAL    APPLIED    ANATOMY       [Part  I 

cipal  being  the  internal  carotid  artery,  the  vagus, 
glossopharyngeal,  and  hypoglossal  nerves  (Fig. 
27,  p.  121).  The  internal  carotid  is  so  close  to 
the  pharynx  that  its  pulsations  may  be  felt  by 
the  finger  introduced  through  the  mouth.  These, 
and  other  deep  structures  in  the  neck,  may  be 
wounded  by  foreign  bodies  that,  passing  in  at 
the  mouth,  have  been  thrust  through  the  pharynx 
into  the  cervical  tissues.  The  internal  jugular 
vein  is  at  some  distance  from  the  pharynx,  especi- 
ally at  its  upper  part  (Fig.  27,  p.  121).  The 
styloid  process,  when  prominent,  and  an  ossified 
stylo-hyoid  ligament,  can  also  be  felt  at  the  side 
of  the  pharynx  immediately  behind  the  tonsil. 
In  more  than  one  case  an  ossified  stylo-hyoid  liga- 
ment has  been  mistaken  for  a  foreign  body,  and 
an  attempt  made  to  excise  it.  Langenbeck  has 
three  times  extirpated  the  pharynx  for  malignant 
disease,  but  without  success.  He  reaches  it  from 
the  neck  through  an  incision  that,  beginning 
below  the  jaw,  midway  between  the  symphysis  and 
angle,  is  carried  over  the  great  cornu  of  the  hyoid 
bone,  and  ends  close  to  the  cricoid  cartilage.  The 
posterior  belly  of  the  digastric  and  the  stylo-hyoid 
muscles  are  detached  from  the  hyoid  bone,  while 
the  omo-hyoid  muscle,  the  lingual,  facial,  and 
superior  thyroid  arteries  and  the  superior  laryn- 
geal nerve  are  divided. 

The  tonsil  is  lodged  between  the  anterior  and 
posterior  palatine  arches.  It  is  in  relation  ex- 
ternally  with  the  superior  constrictor  muscle,  and 
corresponds,  as  regards  the  surface,  to  the  angle 
of  the  lower  jaw.  It  is  questionable  whether  the 
enlarged  tonsil,  when  it  is  the  subject  of  other 
than  malignant  enlargement,  can  ever  be  felt 
externally.  When  hypertrophied,  the  mass  tends 
to  develop  towards  the  middle  line,  where  no 
resistance  is  encountered,  and  to  effect  but  little 
change  in  its  external  relations.  The  mass,  often 
mistaken  for  the  enlarged  tonsil  in  the  neck,  is 
formed  of  enlarged  glands,  situate  near  the  tip  of 
the  great  cornu  of  the  hyoid  bone,  and  overlying 


Chap.  VITI]  .  THE    PHARYNX  156 

the  internal  jugular  vein.  These  glands  receive 
the  tonsillar  lymphatics,  and  are  almost  invari- 
ably enlarged  in  all  tonsil  affections.  The  fact 
that  these  glands  are  so  frequently  the  first  to  en- 
large when  the  cervical  glands  become  tubercular 
points  to  the  tonsil  as  a  common  site  of  primary 
infection.  It  must  be  remembered  that  many 
structures  are  interposed  between  the  tonsil  and 
the  skin,  and  as  the  hypertrophied  body  projects 
freely  into  the  pharygneal  cavity,  one  would  not 
expect  that  it  could  be  readily  felt,  even  were 
the  interposed  tissues  less  extensive  than  they  are. 
The  tonsil  is  closely  enough  attached  to  the 
pharyngeal  wall  to  be  affected  by  the  movements 
of  the  pharyngeal  muscles.  Thus  it  is  moved  in- 
wards by  the  superior  constrictor  muscle  during 
the  act  of  swallowing,  and  may  be  drawn  out- 
wards, on  the  other  hand,  by  the  stylo-pharyngeus 
muscle.  The  ease  with  which  a  tonsil  can  be 
reached  depends,  other  things  being  equal,  upon 
the  extent  to  which  it  can  be  withdrawn  by  the 
stylo-pharyngeus,  and  upon  the  development  of 
the  anterior  palatine  arch,  which,  to  some  extent, 
hides  the  tonsil.  A  child  with  a  prominent  an- 
terior palatine  arch,  containing  a  well-developed 
palato-glossus  muscle,  and  with  a  vigorous  stylo- 
pharyngeus,  can  for  a  long  time  elude  the  tonsil 
guillotine. 

Deafness  is  often  complained  of  when  the  tonsil 
is  hypertrophied.  This  is  not  due  to  closure  of 
th ft  F.iiRta^hifln  tube  hv  the  direct  pressure  of  the 
en  larger]  mass.  Such  pressure  is  anatomically  im- 
possible. T-he—large  tonsil  may,  however,  affect 
the  patency  of  the  tube,  by  disturbing  the  soft 
pjkiate,  and  through  it  the  tensor  palati  muscle. 
which  rs  much  concerned  in  keeping  open  the 
Enstflphian  tube.  The  deafness  in  these  cases  Ts 
probably  due  rather  to  an  extension  of  the  hyper- 
trophic process  to  the  lining  membrane  of  the 
tube  than  to  any  pressure  effects,  since  it  is 
usually  not  improved  until  some  time  after  the 
tonsil  has  been  removed.     The  tonsil  tissue  is  for 


156  SURGICAL    APPLIED    ANATOMY       [Part  I 

the  most  part  collected  around  a  number  of  re- 
cesses. The  decomposition  of  retained  epithelial 
structures  within  those  recesses  produces  the  foetid 
breath  often  noticed  in  cases  of  enlarged  tonsil, 
and  probably  incites  the  attacks  of  inflammation 
to  which  such  tonsils  are  liable  Calculi  may 
form  in  these  crypts  and  give  rise  to  a  spasmodic 
cough.  In  this  case  the  glosso-pharyngeal  nerve 
conveys  the  afferent  impulse  to  the  respiratory 
centre. 

The  tonsil  is  very  vascular,  receiving  bloo d 
from  the  tonsillar  and  pala~tirip  hranohps  nf  thp 
facial  artery,  from  thp.  descending  pglat.inp  hranr-h 
of  the  internal  maxillary,  from  thp  dorsal  is  lin- 
guae     Of      thp      lingual,      aild frnrn      thp      agpPnrlincr 

pharyngeal  Hence  the  operation  of  removing 
the  tonsil  is  often  associated  with  free  bleeding. 
The  internal  carotid  artery  is  close  to  the 
pharynx,  but  some  way  behind  the  gland  (Fig.  27, 
p.  121).  The  vessel  is,  indeed,  about  f  of  an  inch 
posterior  to  that  body,  and  is  in  comparatively 
little  danger  of  being  wounded  when  the  tonsil 
is  excised.  The  internal  jugular  vein  is  a  con- 
siderable distance  from  the  tonsil.  The  facial 
artery,  in  its  cervical  stage,  is  close  to  the  tonsil. 
Of  impo rtant  cervical  structures,  the  nearest  to 
the  tonsil  is  the  glosso-pha,ryngp«  I  tipt-vp,  The 
ascending  pharyngeal  artery  is  also  in,  close  re- 
fation  with  it.  Although  of  small  size,  bleeding 
from  this  vessel  has  proved  fatal,  as  the  following 
interesting  case,  reported  by  Mr.  Morrant  Baker, 
will  show  :  A  man,  aged  23,  fell  when  drunk,  and 
grazed  his  throat  with  the  end  of  a  tobacco- 
pipe  he  was  smoking  at  the  time.  He  thought 
nothing  of  the  accident.  In  two  days  he  came 
to  the  hospital  with  what  appeared  to  be  an 
acutely  inflamed  tonsil.  The  tonsil  was  punc- 
tured, but  nothing  escaped  save  a  little  blood. 
Several  haemorrhages  occurred  from  the  tonsil 
wound,  and  on  the  fourth  day  after  the  accident 
1  inch  of  the  stem  of  a  clay  pipe  was  discovered 
deeply  embedded  in  the  glandular  substance.     It 


Chap.  VIII]  THE    PHARYNX  157 

was  removed,  and  the  common  carotid  tied.  The 
patient,  however,  never  rallied  from  the  previous 
severe  haemorrhages,  and  soon  died.  The  autopsy 
showed  that  the  stem  of  the  pipe,  which  had  not 
been  missed  by  the  patient,  had  divided  the  as- 
cending pharyngeal  artery  (St.  Bart.'s  Hosp. 
Reports,   1876). 

The  tonsil  is  often  the  seat  of  malignant 
fl£oj/)tj3.s.  Such  tumours  have  been  removed 
through  the  mouth,  but  are  more  conveniently 
dealt  with  through  an  incision  in  the  neck  along 
the  anterior  edge  of  the  sterno-mastoid  (  Cheaper/ s 
qpftration). 


CHAPTER    IX 

THE    NECK 

Surface  anatomy;  tooiiy  points.— The  hyoid 
bone  is  on  a  level  with  the  fourth  cervical  vertebra, 
while  the  cricoid  cartilage  is  opposite  the  sixth. 
The  upper  margin  of  the  sternum  is  on  a  level 
with  the  disc  between  the  second  and  third 
dorsal  vertebrae.  (See  p.  173.)  At  the  back  of  the 
neck  there  is  a  slight  depression  in  the  middle 
line  which  descends  from  the  occipital  protuber- 
ance, and  lies  between  the  prominences  formed  by 
the  trapezius  and  complexus  muscles  of  the  two 
sides.  At  the  upper  part  of  this  depression  the 
spine  of  the  axis  can  be  made  out  on  deep  pres- 
sure. Below  this,  the  bony  ridge  formed  by  the 
spines  of  the  third,  fourth,  fifth,  and  sixth  cervi- 
cal, vertebrse  can  be  felt,  but  the  individual  spines 
cannot  usually  be  distinguished.  At  the  root  of 
the  neck  the  spinous  process  of  the  vertebra 
prominens  is  generally  very  obvious.  The  trans- 
verse process  of  the  atlas  may  be  felt  just  below 
and  in  front  of  the  tip  of  the  mastoid  process. 
By  deep  pressure  in  the  upper  part  of  the  supra- 
clavicular fossa,  the  transverse  process  of  the 
seventh  cervical  vertebra  can  be  distinguished. 
If  pressure  be  made  over  the  line  of  the  carotid 
vessels  at  the  level  of  the  cricoid  cartilage, 
the  prominent  anterior  tubercle  of  the  trans- 
verse process  of  the  sixth  cervical  vertebra 
can  be  felt.  This  is  known  as  the  "  carotid  tuber- 
cle."    The    carotid    artery    lies    directly    over    it, 

158 


Chap.  IX]  THE    NECK  159 

and  in  ligaturing  that  vessel  some  surgeons  make 
important  use  of  this  tubercle  as  a  landmark.  If 
a  horizontal  section  of  the  neck,  in  a  muscular 
subject,  taken  about  the  level  of  the  sixth  cervical 
vertebra,  be  viewed,  the  whole  of  the  body  of  the 
vertebra  divided  will  be  seen  to  lie  within  the 
anterior  half  of  the  section. 

The  middle  line. — In  the  receding  angle  be- 
low the  chin  the  hyoid  bone  can  be  felt  and  its 
body  and  greater  cornua  well  made  out.  About 
a  finger's  breadth  below  it  is  the  thyroid  cartilage. 
The  details  of  this  latter  are  readily  distin- 
guished, and  below  it  the  cricoid  cartilage,  crico- 
thyroid space,  and  trachea  can  be  easily  recog- 
nised. The  separate  rings  of  the  trachea  cannot 
be  felt.  The  trachea  is  less  easily  made  out  as  it 
passes  down  the  neck.  As  it  descends  it  takes  a 
deeper  position,  and  at  the  upper  border  of  the 
sternum  lies  nearly  1^  inches  from  the  surface. 

The  rima  glottidis  corresponds  to  the  middle 
of  the  anterior  margin  of  the  thyroid  cartilage. 

Unless  enlarged,  the  thyroid  gland  cannot 
be  made  out  with  certainty.  According  to  Mr. 
Holden,  the  pulse  of  the  superior  thyroid  artery 
can  be  felt  at  its  upper  and  anterior  part. 

The  anterior  jugular  veins  descend  on  either 
side  of  the  middle  line  upon  the  sterno-hyoid  mus- 
cles. They  commence  in  the  submaxillary  region, 
pierce  the  fascia  just  above  the  inner  end  of  the 
clavicle,  and,  passing  beneath  the  origin  of  the 
sterno-mastoid  muscle,  end  in  the  external  jugu- 
lar. The  inferior  thyroid  veins  lie  in  front  of 
the  trachea,  below  the  isthmus. 

The  side  of  the  neck. — Muscles.—  The  sterno- 
mastoid  muscle,  especially  in  thin  subjects  and 
when  thrown  into  action,  is  a  prominent  feature 
in  the  neck.  The  anterior  border  of  the  muscle  is 
very  distinct.  The  posterior  border  is  less  promi- 
nent, especially  at  its  upper  part.  A  communi- 
cating branch  from  the  facial  vein  generally  runs 
along  the,  anterior  border  of  the  muscle  to  meet 
the  anterior   jugular   vein   at  the   lower   part  of 


160  SURGICAL    APPLIED    ANATOMY       [Part  I 

the  neck.  The  interval  between  the  sternal  and 
clavicular  parts  of  the  muscle  is  generally  well 
marked.  If  a  needle  be  thrust  through  this  in- 
terval, quite  close  to  the  clavicle,  it  would  just 
touch  the  bifurcation  of  the  innominate  artery 
on  the  right  side  and  would  pierce  the  carotid 
vessel  on  the  left.  The  posterior  belly  of  the 
digastric  muscle  corresponds  to  a  line  drawn  from 
the  mastoid  process  to  the  anterior  part  of  the 
hyoid  bone.  The  anterior  belly  of  the  omo-hyoid 
follows  an  oblique  line  drawn  downwards  from  the 
fore  part  of  the  hyoid  bone,  so  as  to  cross  the 
line  of  the  carotid  artery  opposite  the  cricoid 
cartilage.  The  posterior  belly  can  be  made  out  in 
thin  necks,  especially  when  in  action,  running 
nearly  parallel  with  and  just  above  the  clavicle. 
Although  not  taking  quite  the  same  direction,  yet 
the  posterior  borders  of  the  sterno-mastoid  and 
anterior  scalene  muscles  practically  correspond 
to  one  another. 

Vessels. — The  common  carotid  artery  is  repre- 
sented by  a  line  drawn  from  the  sterno-clavicular 
joint  to  a  point  midway  between  the  angle  of  the 
jaw  and  the  mastoid  process.  The  vessel  bifur- 
cates at  the  upper  border  of  the  thyroid  cartilage, 
or  not  unfrequently  nearly  \  an  inch  above  that 
point.  The  omo-hyoid  crosses  it  opposite  the 
cricoid  cartilage,  and  at  about  the  same  level  the 
artery  is  crossed  by  the  middle  thyroid  vein.  The 
line  of  the  internal  jugular  vein  is  just  external 
to  that  for  the  main  artery.  Both  the  artery  and 
vein  lie  under  the  anterior  border  of  the  sterno- 
mastoid.  The  superior  thyroid  artery  comes  off 
below  the  great  cornu  of  the  hyoid  bone,  and 
curves  forwards  and  downwards  to  the  upper 
edge  of  the  thyroid  cartilage.  The  great  cornu  of 
the  hyoid  serves  as  an  excellent  guide  to  the  lin- 
gual artery,  which  invariably  forms  a  loop  above 
the  posterior  end  of  that  process  before  proceeding 
forwards  beneath  the  hyo-glossus  muscle  (Fig.  28, 
p.  124).  The  facial  artery  is  very  tortuous,  but  its 
general  course  in  the  neck  is  represented  *by  a  line 


Chap.  IX]  THE    NECK  161 

drawn  from  the  anterior  border  of  the  masseter 
at  the  lower  border  of  the  jaw  to  a  point  just 
above  the  tip  of  the  great  cornu,  while  the  occi- 
pital follows  a  line  that  starts  from  the  latter 
point  and  runs  across  the  base  of  the  mastoid 
process. 

The  external  jugular  vein  follows  a  line  drawn 
from  the  angle  of  the  jaw  to  the  middle  of  the 
clavicle. 

The  subclavian  artery  describes  a  curve  at  the 
root  of  the  neck.  One  end  of  the  curve  corre- 
sponds to  the  sterno-clavicular  joint,  the  other 
end  to  the  centre  of  the  clavicle,  the  summit  of  the 
curve  rising  to  a  point  about  ^  an  inch  above  that 
bone.  In  the  angle  between  the  posterior  edge 
of  the  sterno-mastoid  and  the  clavicle  the  pulsa- 
tions of  the  artery  may  be  felt.  Just  above  the 
bone  the  artery  may  be  compressed  against  the 
first  rib.  The  compression  is  most  easily  applied 
when  the  arm  is  well  drawn  down,  and  the 
direction  of  the  pressure  should  be  downwards 
and  inwards. 

The  subclavian  vein  lies  below  the  artery,  and 
is  entirely  under  cover  of  the  clavicle. 

The  suprascapular  and  transverse  cervical 
arteries  run  parallel  with  the  clavicle,  the  former 
quite  behind  the  bone,  the  latter  just  above  it. 
The  pulsations  of  the  latter  vessel  can  generally 
be  felt. 

Nerves. — The  position  of  the  chief  superficial 
nerves  of  the  neck  may  be  fairly  indicated  by 
six  lines,  all  drawn  from  the  middle  of  the  pos- 
terior border  of  the  sterno-mastoid  muscle.  A  line 
drawn  forwards  from  this  spot  so  as  to  cross  the 
sterno-mastoid  at  right  angles  to  its  long  axis 
corresponds  to  the  superficial  cervical  nerve.  A 
second  line  drawn  up  across  the  muscle  to  the 
back  of  the  pinna,  so  as  to  run  parallel  with  the 
external  jugular  vein,  corresponds  to  the  great 
auricular  nerve ;  and  a  third  line,  running  along 
the  posterior  border  of  the  sterno-mastoid  muscle 
to  the  scalp,  marks  the  course  of  the  small  ocel- 
li 


162  SUEGICAL    APPLIED    ANATOMY       [Part  I 

pital  nerve.  These  lines,  continued  downwards, 
so  as  to  cross  the  sternum,  the  middle  of  the  clavi- 
cle, and  the  acromion,  will  indicate  respectively 
the  suprasternal,  supraclavicular,  and  supra- 
acromial  nerves. 

The  spinal  accessory  nerve  reaches  the  anterior 
border  of  the  sterno-mastoid  muscle  at  a  point 
about  1  inch  below  the  tip  of  the  mastoid  process. 
It  emerges  from  beneath  that  muscle  about  the 
middle  of  its  posterior  border,  crosses  the  pos- 
terior triangle,  and  passes  beneath  the  trapezius 
between  the  middle  and  lower  thirds  of  the  anterior 
border  of  that  muscle  (Fig.  28,  p.  124). 

The  phrenic  nerve  commences  deeply  at  the 
side  of  the  neck,  about  the  level  of  the  mid  point 
of  the  thyroid  cartilage,  and  runs  downwards 
to  a  point  behind  the  sternal  end  of  the  clavicle. 
About  the  level  of  the  cricoid  cartilage  it  lies 
beneath  the  sterno-mastoid  (which  covers  it  wholly 
in  the  neck)  about  midway  between  the  anterior 
and  posterior  borders  of  the  muscle.  The  brachial 
plexus  can  be  felt,  and  even  seen  in  very  thin 
subjects.  Its  upper  limits  may  be  represented 
by  a  line  drawn  across  the  side  of  the  neck  from 
a  point  about  opposite  to  the  crico-thyroid  space 
to  a  spot  a  little  external  to  the  centre  of  the 
clavicle. 

The  skin  in  the  submaxillary  region  is  lax 
and  thin,  and  is  often  found  of  considerable  value 
for  making  flaps  in  plastic  operations  about  the 
mouth.  The  platysma  myoides  is  closely  con- 
nected with  the  skin,  and  to  its  action  is  due  the 
turning-in  of  the  edges  of  such  wounds  as  are 
athwart  the  line  of  direction  of  the  muscle.  The 
amount  of  subcutaneous  fat  in  the  cervical  region 
varies  in  different  parts.  In  the  suprahyoid 
region  it  is  apt  to  undergo  extensive  development, 
producing  the  diffused  lipoma  known  as  "  double- 
chin.'' 

The  skin  over  the  nape  of  the  neck  is  very 
dense  and  adherent,  and  these  two  circumstances, 
in  addition  to  the  free  nerve-supply  of  the  parts, 


Chap.  IX]  THE   NECK  163 

serves  to  explain  the  severe  pain  that  often  accom- 
panies inflammation  in  this  region.  Common  car- 
buncle is  very  often  met  with  behind  at  the  root 
of  the  neck,  in  the  middle  line. 

When  the  sterno-niastoid  muscle  of  one  side  is 
rigidly  contracted,  either  from  paralysis  of  the 
opposite  muscle  or  from  spasmodic  contraction, 
or  from  some  congenital  defect,  the  condition 
known  as  wry-neck  is  produced.  The  position  of 
the  head  in  wry-neck  illustrates  ^  precisely  the 
effect  of  the  sterno-mastoid  when  in  full  action. 
The  head  is  bent  a  little  forwards,  the  chin  is 
turned  towards  the  sound  side,  and  the  ear  on  the 
affected  side  leans  towards  the  sterno-clavicular 
joint.  In  many  cases  the  trapezius  and  splenitis 
muscles  are  also  affected.  Spasmodic  contraction 
of  the  muscle  may  be  due  to  reflex  irritation. 
Thus,  it  has  accompanied  inflammation  of  the  cer- 
vical glands  in  the  posterior  triangle.  Such  in- 
flammation has  irritated  some  branches  of  the 
cervical  plexus,  and  the  sterno-mastoid  muscle, 
although  it  is  supplied  mainly  by  the  spinal  acces- 
sory nerve,  receives  a  nerve  from  that  plexus  (viz., 
from  the  second  cervical).  The  course  of  the  re- 
flex disturbance  in  such  cases  is  therefore  not  diffi- 
cult to  follow.  It  is  to  be  remembered,  too,  that 
the  spinal  accessory  nerve  passes  between  the 
upper  two  or  three  deep  cervical  lymph  glands 
which  may  compress  it.  A  like  contraction  has 
also  been  produced  by  direct  irritation  of  the 
second  cervical  nerve  in  cases  of  disease  of  the 
first  two  cervical  vertebrae.  For  the  relief  of  some 
forms  of  wry-neck,  the  sterno-mastoid  muscle  is 
divided  subcutaneously,  as  in  an  ordinary  teno- 
tomy operation,  about  ^  an  inch  above  its  attach- 
ment to  the  sternum  and  clavicle.  Two  structures 
stand  considerable  risk  of  being  wounded  in  this 
operation,  viz.,  the  external  jugular  vein  lying 
near  the  posterior  border  of  the  muscle,  and  the 
anterior  jugular  which  follows  its  anterior  border 
and  passes  behind  the  muscle,  just  above  the 
clavicle,    to    terminate    in    the    first-named    vein. 


164  SURGICAL    APPLIED    ANATOMY       [Part  I 

With  common  care,  there  should  be  no  risk  of 
wounding  the  great  vessels  at  the  root  of  the  neck. 
For  spasmodic  wry-neck  the  spinal  accessory 
nerve  and  the  communicating  branches  of  the 
third  and  fourth  cervical  nerves  have  been  cut. 
The  spinal  accessory  nerve  is  found  at  the  an- 
terior border  of  the  sterno-mastoid,  1  inch  below 
the  mastoid  process. 

There  is  a  curious  congenital  tumour,  or  in- 
duration, sometimes  met  with  in  this  muscle  in 
the  newly  born.  It  is  usually  ascribed  to  syphilis, 
but,  in  most  cases,  is  probably  due  to  some  tear- 
ing of  the  muscle  fibres  during  the  process  of 
delivery. 

The  cervical  fascia. — The  layers  of  fascia 
that  occupy  the  neck,  and  that  are  known  col- 
lectively as  the  deep  cervical  fascia,  are  dense 
structures,  having  a  somewhat  complex  arrange- 
ment and  a  great  amount  of  importance  from  a 
surgical  point  of  view.  This  fascia  limits  the 
growth  of  cervical  tumours  and  abscesses,  and 
modifies  the  direction  of  their  progress,  but  I  do 
not  think  that  its  effect  in  this  matter  is  quite  so 
definite  as  is  usually  maintained.  It  is  true  that 
deep-seated  cervical  abscesses  are  often  found  to 
follow  just  such  a  course  as  the  arrangement  of 
the  fasciae  would  lead  us  to  suppose,  while,  on 
the  other  hand,  instances  are  by  no  means  un- 
common where  the  abscess  or  growth  appears  to 
ignore  these  membranes  and  adopt  a  course  of 
its  own. 

The  deep  cervical  fascia  may  be  divided  into 
(a)  the  superficial  layer,  and  (b)  the  deeper  pro- 
cesses (see  Fig.   32). 

(a)  The  superficial  layer  forms  a  complete  in- 
vestment for  the  neck,  and  covers  in  all  the  cer- 
vical structures,  except  the  platvsma  and  some 
superficial  veins  and  nerves,  with  the  complete- 
ness of  a  perfectly  fitting  cravat.  It  commences 
behind  at  the  spinous  processes  of  the  vertebra, 
and,  having  invested  the  trapezius  muscle,  starts, 
at  the  anterior  border  of  that  muscle,  as  a  single 


Chap.  IX] 


THE   NECK 


165 


layer,  to  cross  the  posterior  triangle.  Arriving 
at  the  posterior  border  of  the  sterno-mastoid 
muscle,  it  splits  to  enclose  that  structure,  appear- 
ing again  as  a  single  layer  at  the  anterior  border  of 
the  muscle,  from  whence  it  passes  to  the  middle 
line  of  the  neck  to  join  the  fascia  of  the  opposite 


Fig.  32. — Transverse  section  through  the  lower  part  of  the  neck,  to  show 
the  arrangement  of  the  cervical  fascia  (diagrammatic). 

a.  Trapezius ;  b,  sterno-mastoid  ;  c,  depressors  of  hyoid  bone ;  d,  platysma ;  e 
anterior  spinal  muscles  ;  /,  scalenus  amicus  j  </,  carotid  artery  ;  h,  externa 
jugular  vein:  i,  posterior  spinal  muscles;  t,  trachea,  with  gullet  behind  and 
thyroid  body  in  front. 


side,  entirely  covering  in  on  its  way  the  anterior 
triangle.  The  part  that  occupies  the  posterior 
triangle  is  attached  above  to  the  mastoid  process 
and  superior  curved  line  of  the  occipital  bone, 
and  below  to  the  clavicle,  so  that  the  space  is  com- 
pletely closed  in  by  the  fascia  in  all  parts,  al- 
though, just  above  the  clavicle,  it  is  pierced  by 
the  external  jugular  vein  on  its  way  to  the  deeper 
trunks.      Over    the    anterior    triangle    the    fascia 


lm  SURGICAL    APPLIED    ANATOMY      [Part  I 

is  attached  above  to  the  border  of  the  lower  jaw. 
Behind  that  bone  it  passes  over  the  parotid  gland 
to  the  zygoma,  forming  the  parotid  fascia,  while 
a  deeper  layer  passes  beneath  the  gland  (between 
it  and  its  submaxillary  colleague),  to  be  attached 
to  points  at  the  base  of  the  skull.  It  is  from  this 
deeper  part  that  the  stylo-maxillary  ligament  is 
developed.  In  front  the  fascia  is  attached  to  the 
hyoid  bone,  and  just  below  the  thyroid  body  it 
divides  into  two  layers  again,  one  to  be  attached 
to  the  front  of  the  sternum  and  the  other  to  the 
back.  Both  these  layers  lie  in  front  of  the  de- 
pressors of  the  hyoid  bone,  and  they  form  between 
them  a  little  space  (which  extends  so  far  later- 
ally as  to  enclose  the  sternal  head  of  the  sterno- 
mastoid),  the  widest  part  of  which  is  below,  and 
which  there  corresponds  in  width  to  the  thickness 
of  the  sternum.  It  will  be  perceived  that,  in 
dividing  the  sternal  head  of  the  sterno-mastoid, 
the  operation  is  performed  within  this  little  cham- 
ber formed  by  the  two  layers  just  named,  and  it 
is  well  to  note  that  the  anterior  jugular  vein 
also  occupies  this  chamber  on  its  way  to  the 
external  jugular  trunk.  This  superficial  layer  of 
the  fascia,  considered  generally,  would  oppose  in 
all  parts  the  progress  of  abscesses  or  growths  to- 
wards the  surface,  and  would  encourage  or  com- 
pel them  to  take  a  deeper  position. 

(6)  The  deeper  processes.  (1)  From  the  super- 
ficial layer  a  process  comes  off  near  the  anterior 
border  of  the  sterno-mastoid  muscle,  which,  pass- 
ing beneath  the  depressors  of  the  hyoid  bone,  in- 
vests the  thyroid  body  and  front  of  the  trachea, 
and  passes  down,  in  front  of  that  tube  and  of  the 
large  vessels,  to  the  fibrous  layer  of  the  peri- 
cardium. (2)  The  prevertebral  fascia  is  a  layer 
that  descends  on  the  prevertebral  muscles  behind 
the  pharynx  and  gullet.  It  is  attached  above 
to  the  base  of  the  skull,  and,  below,  descends  into 
the  thorax,  behind  the  oesophagus.  Laterally,  it 
joins  the  carotid  sheath,  and  is  then  prolonged 
outwards  and  downwards  over  the  scalene  muscles, 


Chap.  IX]  THE   NECK  167 

the  brachial  plexus,  and  subclavian  vessels.  It 
follows  these  vessels  beneath  the  clavicle,  where 
it  forms  the  axillary  sheath  and  becomes  con- 
nected with  the  under  surface  of  the  costo-cora- 
coid  membrane.  (3)  The  sheath  of  the  carotid 
artery  and  its  accompanying  vein  and  nerve  is 
derived  in  part  from  fascia  No.  1,  and  in  part 
from  fascia  No.  2. 

The  effects  of  this  disposition  of  the  fascia 
may  be  illustrated  by  noting  the  course  probably 
taken  by  cervical  abscesses  in  various  positions. 
(1)  An  abscess  in  the  posterior  triangle  will  be 
bounded  towards  the  surface  by  the  superficial 
layer  of  fascia.  Towards  the  floor,  or  deep  part, 
of  the  triangle  it  will  be  bounded  by  the  lateral 
portion  of  fascia  No.  2.  The  abscess  may  extend 
some  way  under  the  clavicle  until  arrested  by  the 
union  of  the  costo-coracoid  membrane  with  fascia 
No.  2.  It  would  readily  extend  under  the  edge 
of  the  trapezius  muscle,  and  could  pass  beneath 
the  sterno-mastoid  muscle  and  carotid  artery  to 
the  anterior  and  deeper  parts  of  the  neck.  (2) 
An  abscess  in  the  anterior  triangle  in  front  of  the 
depressors  of  the  hyoid  bone  would  probably  come 
forward,  owing  to  the  thinness  of  the  fascia  in 
front  of  it;  but,  if  pent  up,  it  would  tend  to 
progress  towards  the  anterior  mediastinum  or 
into  the  lateral  parts  of  the  neck  in  front  of  the 
carotid  vessels.  (3)  An  abscess  behind  the  hyoid 
depressors  and  about  the  trachea  or  thyroid  body, 
or  in  the  immediate  vicinity  of  the  carotid  ves- 
sels (an  abscess  situate,  in  fact,  between  the  deep 
fasciae  Nos.  1  and  2),  would  find  itself  in  a  nar- 
row strait,  and  after  pressing  much  upon  adja- 
cent parts  would  most  readily  spread  downwards 
into  the  mediastinum.  (4)  An  abscess  immedi- 
ately in  front  of  the  spine,  and  beneath  the  deep 
fascia  No.  2,  might  extend  down  into  the  posterior 
mediastinum,  or  move  towards  the  posterior  and 
lateral  parts  of  the  neck,  following  the  brachial 
plexus,  and  so  reach  the  posterior  triangle,  or 
even  the  axilla. 


168  SUEGlCAL    APPLIED    ANATOMY       [Part  I 

In  many  cases  a  cervical  abscess  has  burst  into 
the  gullet,  or  trachea,  and  even  into  the  pleura. 
In  some  instances  the  great  vessels  have  been 
opened  up.  In  one  remarkable  case  reported  by 
Mr.  Savory  {Med.  Chir.  Trans.,  1881),  not  only 
was  a  considerable  portion  of  the  common  carotid 
artery  destroyed  by  the  abscess,  but  also  a  still 
larger  portion  of  the  internal  jugular  vein  and  a 
large  part  of  the  vagus  nerve.  This,  and  like 
examples  of  the  destructive  action  of  some  cervical 
abscesses,  depend,  no  doubt,  upon  the  unyielding 
character  of  the  cervical  fascia,  which  hems  in 
the  pus  on  all  sides,  and  drives  it  to  resort  to 
desperate  measures  to  effect  an  escape.  "  It  is 
noteworthy/5  remarks  Mr.  Jacobson,  "  that  com- 
munications between  abscesses  and  deep  vessels 
have  usually  taken  place  beneath  two  of  the 
strongest  fasciae  in  the  body,  the  deep  cervical 
fascia  and  the  fascia  lata  "  (Hilton's  "  Rest  and 
Pain  "). 

The  apex  of  the  lung*  extends  into  the 
neck,  and  reaches  a  point  from  1  to  2  inches 
above  the  inner  half  of  the  clavicle.  A  point 
between  the  sternal  and  clavicular  heads  of  the 
sterno-mastoid  and  l\  inches  above  the  clavicle 
will,  in  the  majority  of  adults,  mark  the  highest 
point  of  the  apex  and  the  position  of  the  neck  of 
the  first  rib.  It  lies  behind  the  clavicle,  anterior 
scalene  muscle,  and  subclavian  vessels.  The  right 
lung  commonly  extends  higher  up  than  the  left. 

The  pleura  has  been  opened  in  careless  opera- 
tions on  the  subclavian  artery,  and  has  also  been 
torn  in  dragging  deep-seated  tumours  from  the 
base  of  the  neck.  The  pleura  and  lung  have  been 
wounded  in  stabs  of  the  neck  and  by  fragments 
of  bone  in  severe  fractures  of  the  clavicle.  Cer- 
vical abscesses  have  opened  into  the  pleura,  and, 
apart  from  this,  pleurisy  has  followed  inflamma- 
tion of  the  cellular  tissue  at  the  root  of  the  neck. 
Sibson's  fascia,  which  is  attached  along  the  inner 
border  of  the  first  rib,  strengthens  the  pleura  over 
the  apex  of  the  lung. 


Chap.  IX] 


THE   NECK 


169 


Cervical  ribs.  —  These  structures  have  led 
to  many  errors  in  diagnosis,  have  been  mistaken 
for  exostoses,  and  where  the  subclavian  artery  is 
carried  over  them,  which  is  usually  the  case  (Fig. 
33),  have  led  to  the  diagnosis  of  aneurism.  They 
are  met  with  at  all  ages  and  in  both  sexes,  and 


jFlFTH  CERV./lE&VE. 


hCarotid  Tubercle 

TRAC/iEA 
zriElCHTrt  Cerv./Ierve 
^-Cervical  Rib 
J-Subclaviam  Art. 
fCAROTiD  Art. 

Sibson's  Fascia 
l/iMOMiftATE  Art. 

Clavicle 


[AIa/nubriuai 


Fig.  33. — Showing  the  relationship  of  the  subclavian  artery  and  brachia 
plexus  to  a  cervical  rib.  » 

represent  the  cervical  ribs  of  lower  vertebrates. 
In  most  cases  one  such  rib  is  found  on  either  side 
of  the  seventh  cervical  vertebra ;  sometimes  it  is 
movable,  sometimes  it  is  ankylosed  to  the  vertebra 
and  its  transverse  process.  A  rudiment  is  always 
present  in  the  foetus.  It  may  be  very  short,  and 
represented  only  by  a  head,  neck,  and  tubercle. 
Such    forms    have    been    mistaken    for    exostoses. 


170  SURGICAL    APPLIED    ANATOMY      [Part  I 

It  may  be  long,  and  may  then  end  free,  or  be 
joined  to  the  first  rib  or  the  first  costal  cartilage 
by  ligament,  or  even  by  cartilage.  In  such  in- 
stances the  subclavian  artery  passes  over  the 
cervical  rib,  its  pulsations  being  very  distinctly 
seen  and  felt.  To  the  longer  form  of  cervical  ribs 
the  scalenus  anticus  and  the  scalenus  medius 
may  be  attached.  Occasionally  subjects  of  this 
anomaly  complain  of  numbness  along  the  ulnar 
side  of  the  arm  and  hand,  or  of  partial  paralysis 
of  the  muscles  of  the  hand.  These  symptoms  are 
due  to  traction  on  the  first  dorsal  nerve  at  the 
point  where  it  crosses  above  the  cervical  rib 
(Thorburn).  (See  Fig.  33.)  In  thin  subjects  the 
rib  can  be  seen  as  a  distinct  projection  in  the  neck. 
Cut  throat  and  wounds  of  the  neck.— 
The  skin  of  the  neck  is  so  elastic  and  mobile  that 
it  is  readily  thrown  into  folds  when  a  knife, 
and  especially  a  blunt  knife,  is  drawn  across  it. 
Thus,  in  cases  of  cut  throat  several  distinct  skin 
cuts  may  be  found  that  were  all  produced  by  one 
movement  of  the  knife.  The  wound  in  cut  throat, 
whether  suicidal  or  homicidal,  most  frequently 
involves  the  thyro-hyoid  membrane,  next  in  fre- 
quency the  trachea,  and  then  the  thyroid  car- 
tilage. 

1.  If  the  wound  be-  above  the  hyoid  bone  the 
following  parts  may  be  cut  :  Anterior  jugular 
vein ;  anterior  belly  of  digastric ;  mylo-hyoid, 
genio-hyoid,  genio-hyo-glossus,  and  hyo-glossus 
muscles ;  the  lingual  artery ;  branches  of  the  facial 
artery ;  the  hypoglossal  and  gustatory  nerves ; 
tjie  submaxillary  gland.  The  substance  of  the 
tongue  may  be  cut,  and  the  floor  of  the  mouth 
freely  opened.  In  any  case  where  the  attachments 
of  the  tongue  are  divided  the  organ  is  apt  to  fall 
back  upon  the  larynx  and  produce  suffocation. 

2.  If  the  wound  be  across  the  thyro-hyoid  space 
the  following  may  be  the  parts  cut :  Anterior 
jugular  vein;  sterno-hyoid,  thyro-hyoid,  omo- 
hyoid muscles ;  thyro-hyoid  membrane ;  inferior 
constrictor ;    superior    laryngeal    nerve ;    superior 


Chap.  tx]  THE   NECK  171 

thyroid  artery ;  and  if  near  the  hyoid  bone  the 
trunk  of  the  lingual  artery  may  be  cut.  The 
pharynx  would  be. opened  in  a  deep  wound,  and 
the  epiglottis  divided  near  its  base.  Division  of 
the  epiglottis  in  wrounds  in  this  situation  is  always 
a  serious  complication. 

3.  If  the  wound  involve  the  trachea  the  follow- 
ing may  be  the  parts  cut  :  Anterior  jugular 
vein ;  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid 
muscles;  part  of  sterno-mastoid ;  thyroid  gland; 
superior  and  inferior  thyroid  arteries ;  superior, 
middle,  and  inferior  thyroid  veins;  recurrent 
laryngeal  nerves  and  the  gullet. 

In  wounds  of  the  neck  the  great  vessels  often 
escape  in  a  marvellous  manner.  They  are  pro- 
tected in  part  by  the  depth  at  which  they  are 
situated,  and  in  part  by  their  great  mobility, 
lying  as  they  do  in  an  atmosphere  of  loose  con- 
nective tissue.  Dieffenbach  relates  a  case  of  cut 
throat  in  which  both  gullet  and  trachea  were 
divided  without  any  damage  to  the  great  vessels. 
In  cut  throat  the  vessels  are  greatly  protected 
by  the  projecting  thyroid  cartilage  above  and  by 
the  contracting  of  the  sterno-mastoid  muscles 
below.  Deep  gashes  made  across  the  crico-thy- 
roid  space,  or  through  the  upper  part  of  the 
trachea,  reach  the  great  vessels  more  easily  than 
would  wounds  made  with  equal  force  in  any  other 
part  of  the   neck. 

In  some  cases  of  gunshot  wound  the  vessels 
seem  to  have  been  actually  pushed  aside,  and  to 
have  owed  their  safety  to  their  mobility.  Thus, 
in  a  case  reported  by  Longmore,  the  bullet  passed 
entirely  through  the  neck  from  one  side  to  the 
other.  It  passed  through  the  gullet,  damaged  the 
posterior  part  of  the  larynx,  but  left  the  great 
vessels  intact.  In  another  recorded  case  a  boy 
fell  upon  the  point  of  a  walking-stick.  The  end 
of  the  stick  passed  entirely  through  the  neck 
from  side  to  side,  entering  in  front  of  one  sterno- 
mastoid  muscle  and  emerging  through  the  sub- 
stance  of  the   opposite   one.     It  probably   passed 


172  SURGICAL    APPLIED    AN  ATOM'S       [Part  I 

between  the  pharynx  and  the  spine.  The  boy, 
who  left  the  hospital  well  in  eighteen  days,  owed 
his  safety  to  the  laxity  of  the  cervical  connective 
tissue  and  to  the  mobility  of  the  main  structures 
in  the  neck.  The  structures  of  the  neck  are  fixed 
laxly  to  allow  movements  of  the  larynx  and 
tongue. 

In  connection  with  the  subject  of  wounds  of  the 
neck  it  must  be  remembered  that  the  most  im- 
portant part  of  the  spinal  cord  can  be  reached 
from  behind,  through  the  gap  between  the  atlas 
and  axis.  In  this  situation  the  cord  has  been 
divided  by  one  stab  of  a  knife,  the  instrument 
entering  between  the  two  bones.  Langier  gives 
some  ingenious  cases  of  infanticide  where  the 
lethal  weapon  was  merely  a  long  needle.  The 
needle  was  introduced  into  the  spinal  canal  be- 
tween the  atlas  and  the  axis,  and  the  cord  readily 
cut  across. 

Wounds  at  the  side  of  the  neck  have  divided 
considerable  portions  of  the  brachial  plexus  with- 
out involving  other  structures. 

The  liyoid  bone  may  be  broken  by  direct  vio- 
lence, as  from  blows,  or  in  the  act  of  throttling. 
It  is  sometimes  found  broken  in  those  who  have 
been  hanged.  The  fracture  may  involve  the 
body  of  the  bone,  but  more  usually  the  greater 
cornu  is  found  broken  off.  In  the  New  York 
Medical  Record  (1882)  is  the  report  of  the  case 
of  a  man  who  felt  something  snap  under  his  chin 
while  yawning.  On  examination  the  hyoid  bone 
was  found  to  be  fractured.  The  bone  was  also 
found  broken  in  a  patient  who  threw  her  head 
violently  backwards  to  save  herself  from  falling 
(Hamilton).  The  fracture  is  associated  with 
great  difficulty  and  pain  in  speaking,  in  moving 
the  tongue,  in  opening  the  mouth,  and  in  swallow- 
ing, symptoms  that  may  be  readily  understood 
A  bursa  lies  between  the  thyro-hyoid  membrane 
and  the  posterior  surface  of  the  hyoid  bone.  It 
may,  when  enlarged,  form  one  of  the  cystic  tumours 
of  the  neck. 


Chap.  IXJ  THE   NECK  173 

The  larynx  and  trachea.— The  position  of 
the  larynx  in  the  neck  is  influenced  by  age.  In 
the  adult  the  cricoid  cartilage  reaches  to  the  lower 
part  of  the  sixth  cervical  vertebra.  In  a  child 
of  three  months  it  reaches  the  lower  border  of 
the  fourth  cervical,  and  in  a  child  of  six  years 
the  lower  border  of  the  fifth  vertebra.  At  puberty 
it  attains  the  adult  position.  The  upper  end  of 
the  epiglottis  in  the  adult  is  opposite  the  lower 
border  of  the  third  cervical  vertebra.  With  the 
laryngoscope  the  following  parts  may  be  made 
out  (Fig.  34)  :  The  base  of  the  tongue  and  glosso- 
epiglottic  ligaments ;  the  superior  aperture  of  the 
larynx,  presenting  in  front  the  epiglottis,  at  the 
sides  the  aryteno-epiglottidean  folds  (in  which  are 
two  rounded  eminences  corresponding  to  the 
cornicula  and  cuneiform  cartilages),  and  at  the 
back  the  arytenoid  commissure  of  mucous  mem- 
brane. Deeply  down  can  be  seen  the  true  and 
false  vocal  cords,  the  ventricle,  the  anterior  wall 
of  the  larynx,  a  little  of  the  cricoid  cartilage, 
and  more  or  less  of  the  anterior  wall  of  the 
trachea.  If  the  glottis  be  very  fully  dilated 
the  openings  of  the  two  bronchi  may  be  dimly 
seen. 

The  thyroid  and  cricoid  cartilages  and  the 
greater  part  of  the  arytenoid  are  in  structure 
hyaline,  as  are  the  costal  cartilages.  Like  the 
last-named,  they  are  liable  to  become  more  or  less 
ossified  as  life  advances.  Ossification  commences 
in  the  thyroid  and  cricoid  cartilages  at  about 
the  age  of  20,  and  in  either  cartilage  the  process 
commences  in  the  vicinity  of  the  crico-thyroid 
joint.  The  arytenoid  ossifies  later.  Ossification 
of  the  laryngeal  cartilages  is  more  marked  in 
males  than  in  females.  The  larger  cartilages  are 
liable  to  be  fractured  by  violence,  as  by  blows, 
throttling,  etc.  The  thyroid  is  the  one  most  fre- 
quently broken,  and  usually  in  the  median  line. 
The  posterior  superior  angle  of  the  thyroid  car- 
tilage marks  the  position  of  the  pyriform  fossa, 
a  wide  recess5  above  and  external  to  the  aryteno- 


174 


SURGICAL    APPLIED    ANATOMY       [Part  I 


epiglottic   folds    (Fig.    34).     Foreign   bodies   may 
be  arrested  in  this  fossa. 

The  riiusi  glottidis  is  the  aperture  between 
the  true  vocal  cords  and  the  vocal  processes  of  the 
arytenoid,  to  which  the  cords  are  attached  pos- 
teriorly. The  cords  are  double  the  length  of  the 
processes,  and  are  of  a  grey  buff  colour,  owing 
to  the  elastic  tissue,  of  which  they  are  mainly 
composed,  being  apparent  beneath  the  stratified 
epithelium.     The   rima  is  the  narrowest  part  of 


Fig.  34. — The  upper  aperture  of  the  larynx  iu  the  open  (a)  and  shut  (k 

positions. 

A, Cushion  of  epiglottis;  b,  apices  of  arytenoids;  c,  aryreno-epiglottidean  folds  ; 
E,  posterior  aspect  of  cricoid  ;  p,  false  vocal  cords;  g,  rima  glottidis,  between 
true  vocal  cords ;  h,  posterior  border  of  thyroid  cartilage ;  i,  tip  of  great  born 
of  hyoid. 

the  interior  of  the  larynx,  and  it  is  well  to  be 
familiar  with  its  proportions  in  reference  to  the 
entrance  of  foreign  bodies  and  the  introduction 
of  instruments.  In  the  adult  male  the  rima  mea- 
sures nearly  1  inch  (23  mm.)  from  before  back- 
wards; from  side  to  side,  at  its  widest  part,  it 
measures  about  one-third  of  the  length ;  this  dia- 
meter may  be  increased  to  one-half  of  the  length 
in  extreme  dilatation.  In  the  female  and  in  the 
male  before  puberty  the  antero-posterior  diameter 
is  from  17  mm.  The  rima  is  widely  opened  dur- 
ing inspiration,  owing  to  the  action  of  the    crico- 


Chap.  IX]  THE    NECK  175 

arytenoideus  posticus,  while  the  vocal  cords  are 
approximated  in  speech  under  the  influence  of  the 
crico-arytenoideus   lateralis. 

The  mucous  membrane  of  the  larynx  varies 
in  thickness  in  different  parts,  and  in  the  amount 
of  its  submucous  tissue.  The  membrane  is  thick- 
est, and  the  submucous  tissue  most  abundant,  in 
the  following  parts,  taken  in  order  of  degree  : 
The  aryteno-epiglottidean  folds,  the  mucous  mem- 
brane of  the  ventricle,  the  false  cords,  and  the 
laryngeal  aspect  of  the  epiglottis.  These  are  the 
parts  that  become  most  congested  and  swollen  in 
acute  laryngitis  :  and  the  serious  condition  known 
as  oedema  of  the  glottis  depends  mainly  upon 
effusion  into  the  lax  submucous  tissue  in  the 
aryteno-epiglottidean  folds.  The  lax  condition  of 
the  mucous  membrane  of  the  aryteno-epiglottidean 
folds  allows  free  movements  of  the  arytenoid 
cartilages  and  complete  closure  of  the  upper 
aperture  of  the  larynx  (Fig.  34).  The  mucous 
membrane  is  firmly  bound  to  the  true  vocal  cords 
and  covered  by  stratified  epithelium,  while  the 
rest  of  the  larynx  is  lined,  like  the  trachea,  with 
ciliated  epithelium.  Owing  to  the  nature  of  its 
covering  and  exposure  to  friction,  the  true  vocal 
cord  is  not  an  uncommon  site  of  epithelioma.  The 
affection  known  as  "  clergyman's  sore  throat  "  has 
an  interesting  anatomical  basis.  The  mucous 
membrane  of  the  larynx  is  well  provided  with 
mucous  glands,  whose  function  it  is  to  keep  moist 
the  parts  concerned  in  phonation.  When  an  in- 
dividual speaks  aloud  for  a  long  time  the  lining 
of  the  larynx  tends  to  become  dry,  on  account 
of  the  large  amount  of  cold  air  that  is  drawn 
in  directly  through  the  mouth.  To  keep  these 
parts  moist  the  mucous  glands  have  to  exhibit 
increased  energy,  and  in  those  who  speak  much 
in  public  the  glands  may  in  time  become  so  over- 
worked as  to  inflame.  It  is  the  inflammation 
of  these  glands  that  constitutes  the  present  affec- 
tion. The  glands  are  not  distributed  equally  over 
all  parts  of  the  larynx,   but  are  most  numerous 


176  SURGICAL    APPLIED    ANATOMY       [Part  I 

in  the  membrane  covering  the  arytenoid  cartilages 
and  parts  immediately  about  them,  the  base  of 
the  epiglottis,  and  the  interior  of  the  ventricle. 
It  is  in  these  parts,  therefore,  that  the  changes 
in  chronic  glandular  laryngitis,  or  dysphonia 
clericorum,  are  most  marked. 

Excision  of  the  laryiix.— The  entire  larynx 
has  been  removed  for  carcinomatous  disease,  but 
the  operation,  although  not  immediately  fatal, 
has  not  been  followed  by  very  satisfactory  results. 
It  is  removed  through  an  incision  in  the  middle 
line.  In  this  incision  are  divided  the  platysma, 
the  fascia,  and  the  anterior  jugular  vein.  The 
larynx  is  separated  from  its  connections,  the  fol- 
lowing structures  being  divided  :  sterno-thyroid, 
thyro-hyoid,  stylo-pharyngeus,  palato-pharyngeus, 
and  inferior  constrictor  muscles,  laryngeal 
branches  of  the  superior  and  inferior  thyroid 
arteries,  superior  and  inferior  laryngeal  nerves, 
hyo-epiglottic  and  glosso-epiglottic  ligaments.  The 
larynx  is  then  separated  from  the  trachea,  and  is 
dissected  off  from  below  up.  In  separating  the 
gullet  and  pharynx  there  is  great  risk  of  "  button- 
holing "  the  former  tube.  Growths  and  foreign 
bodies  may  be  removed  from  the  larynx  by  the 
operation  of  thyrotomy:  the  two  alse  of  the  thyroid 
are  separated  along  the  middle  line  and  pulled 
apart,  thus  exposing  the  interior  of  the  larynx. 
In  subjects  over  45  years  of  age  the  cartilage  be- 
comes ossified  in  the  middle  line,  and  will  require 
division  by  a  fine  saw.  It  should  be  remembered 
that  the  vocal  cords  are  attached  on  each  side  of 
the  median  line  near  the  mid  point  of  the  anterior 
border  of  the  thyroid  cartilage,  while  just  above 
them  are  fixed  the  false  vocal  cords  and  stalk  of 
the  epiglottis. 

The  lymphatic  vessels  of  the  upper  half  of  the 
larynx  follow  the  superior  laryngeal  vessels  and 
pass  to  the  upper  deep  cervical  glands.  A  small 
lvmphatic  gland,  the  first  to  become  the  seat  of 
secondary  cancerous  deposit,  is  situated  below 
the  horn  of  the  hyoid  on  the  thyro-hyoid  mem- 


Chap.  IX]  THE   NECK  177 

brane  (Fig.  35,  p.  190).  The  lymphatics  of  the 
lower  half  of  the  larynx  accompany  the  inferior 
thyroid  vessels  and  pass  through  lymph  glands 
by  the  side  of  the  trachea. 

Tracheotomy  and  laryngotomy. — The  trachea 
is  about  4^  inches  in  length,  and  from  f  to 
1  inch  in  its  extreme  width.  It  is  surrounded 
by  an  atmosphere  of  very  lax  connective ;  tissue, 
which  allows  a  considerable  degree  of  mobility  to 
the  tube.  The  mobility  of  the  trachea  is  greater 
in  children  than  in  adults,  and  adds  much  to  the 
difficulties  of  tracheotomy.  In  this  procedure  the 
windpipe  is  opened  in  the  middle  line  by  cutting 
two  or  three  of  its  rings  above,  below,  or  through 
the  isthmus  of  the  thyroid  gland.  Since  the 
trachea,  as  it  descends,  lies  further  from  the  sur- 
face, and  comes  in  relation  with  more  and  more 
important  structures,  it  is  obvious  that,  other 
things  being  equal,  the  higher  in  the  neck  the 
operation  can  be  done  the  better.  The  length  of 
trachea  in  the  neck  is  not  so  considerable  as 
might  at  first  appear,  and,  according  to  Holden, 
not  more  than  some  seven  or  eight  of  the  tracheal 
rings  (which  number  sixteen  to  twenty  in  all)  are 
usually  to  be  found  above  the  sternum.  The  dis- 
tance between  the  cricoid  cartilage  and  the  sternal 
notch  varies  greatly,  and  depends  upon  the  length 
of  the  neck,  the  age  of  the  patient,  and  the  posi- 
tion of  the  head.  If  2  inches  of  trachea  are  ex- 
posed above  the  sternum  when  the  head  rests  easily 
upon  the  spine,  then  in  full  extension  of  the  head 
some  |  of  an  inch  more  of  the  windpipe  will,  as 
it  were,  be  drawn  up  into  the  neck.  According 
to  Tillaux,  the  average  full  distance  between  the 
cricoid  cartilage  and  the  sternum  is,  in  the  adult, 
about  2f  inches  (7  cm.).  The  full  distance  in  a 
child  between  three  and  five  years  is  about  1^ 
inches  (4  cm.),  in  a  child  between  six  and  seven 
about  2  inches  (5  cm.),  and  in  children  between 
eight  and  ten  years  about  2|  inches  (6  cm.).  As 
may  be  imagined,  the  dimensions  of  the  trachea 
on  section  vary  greatly  at  different  ages,  and  even 

M 


178  SURGICAL    APPLIED    ANATOMY       [Part  I 

in  different  individuals  of  the  same  age.  This 
leads  to  the  question  as  to  the  proper  diameter 
of  tracheotomy  tubes.  Guersant,  who  has  paid 
much  attention  to  this  matter,  says  that  the  dia- 
meter of  the  tubes  should  run  from  6  mm.  to 
15  mm.*  The  tubes  with  a  diameter  of  from 
12  mm.  to  15  mm.  are  for  adults.  The  tubes  below 
12  mm.  are  for  children,  and  are  divided  into 
four  sets. 

No     1    i  with  a  dia*  1  fi  mm    i  is  suitable  for  1 11  +n  4  vears  of  a?P 
JSo-  1- 1    meter  of    ]  b  mm"  1  children  from  f  ±2  t0  4  years  ot  age> 

No.  2.  ,,  8  mm.  ,,  4  to    8  „ 

No.  3.  „  10  mm.  „  8  to  12 

No.  4.  „  12  mm.  ,,  12  to  15 

For  children  under  eighteen  months  the  dia- 
meter of  the  tube  should  be  about  4  mm. 

In  performing  tracheotomy  it  is  most  im- 
portant that  the  head  be  thrown  as  far  back  as 
possible,  and  that  the  chin  be  kept  strictly  in  a 
line  with  the  sternal  notch,  so  that  the  relations 
of  the  middle  line  of  the  neck  be  preserved.  Full 
extension  of  the  head  not  only  gives  the  surgeon 
increased  room  for  the  operation,  but  also  brings 
the  trachea  nearer  to  the  surface,  and  by  stretch- 
ing the  tube  renders  it  much  less  mobile. 

In  cutting  down  upon  the  trachea  in  the 
middle  line  of  the  neck  from  the  cricoid  cartilage 
to  the  sternum  the  following  parts  are  met  with  : 
Beneath  the  integument  lie  the  anterior  jugular 
veins.  As  a  rule  these  veins  lie  some  little  way 
apart  on  either  side  of  the  median  line,  and  do 
not  communicate  except  by  a  large  transverse 
branch  which  lies  in  the  interfascial  space  at  the 
upper  border  of  the  sternum.  Sometimes  there 
are  many  communicating  branches  right  in  front 
of  the  tracheotomy  district,  or  the  veins  may 
form  almost  a  plexus  in  front  of  the  trachea,  or 
there  may  be  a  single  vein  which  will  follow  the 
middle  line.  Then  comes  the  cervical  fascia, 
enclosing    the     sterno-hyoid     and     sterno-thyroid 

*  The  reader  may  be  reminded  that  12  mm.  =  about  I  an  inch,  and 
6  mm.,  therefore,  =  about  \  of  an  inch. 


Ohap.  IX]  THE   NECK  179 

muscles.  The  gap  between  the  muscles  of  opposite 
sides  is  lozenge-shaped,  and  is  such  that  the 
trachea  can  be  exposed  without  dividing  muscle 
fibres.  The  isthmus  of  the  thyroid  usually  crosses 
the  second,  third,  and  fourth  rings  of  the  trachea. 
Above  it  a  transverse  communicating  branch  be- 
tween the  superior  thyroid  veins  is  sometimes 
found.  Over  the  isthmus  is  a  venous  plexus,  from 
which  the  inferior  thyroid  veins  arise,  while  be- 
low the  isthmus  these  veins  lie  in  front  of  the 
trachea  together  with  the  thyroidea  ima  <  artery 
(when  it  exists).  The  inferior  thyroid  vein  may 
be  represented  by  a  single  trunk  occupying  the 
middle  line.  In  the  infant  before  the  age  of  two 
years  the  thymus  extends  up  for  a  variable  dis- 
tance in  front  of  the  trachea.  At  the  very  root 
of  the  neck  the  trachea  is  crossed  by  the  innomi- 
nate and  left  carotid  arteries  and  by  the  left 
innominate  vein ;  and  lastly,  abnormal  branches 
of  the  superior  thyroid  artery  may  cross  the 
upper  rings  of  the  windpipe. 

The  evil  of  wounding  the  thyroid  isthmus  is 
greatly  exaggerated.  I  have  frequently  divided 
this  structure  in  performing  tracheotomy  without 
any  inconvenience  resulting.  Like  other  median 
raphes,  the  middle  line  of  the  thyroid  isthmus  has 
but  a  slight  vascularity,  and  it  has  been  shown 
that  one  side  of  the  thyroid  gland  cannot  be  in- 
jected from  the  other  (i.e.  by  injection  that  would 
cross  the  isthmus).  The  difficulty  of  tracheotomy 
in  infants  depends  upon  the  shortness  of  the 
neck,  the  amount  of  the  subcutaneous  fat,  the 
depth  at  which  the  trachea  lies,  its  small  size,  its 
great  mobility,  and  the  ease  with  which  it  can  be 
made  to  collapse  on  pressure.  To  the  finger, 
roughly  introduced,  the  infant's  trachea  offers 
little  resistance.  Its  mobility  is  such  that  we 
hear  of  its  being  held  aside  unknowingly  by  re- 
tractors while  the  operator  is  scoring  the  oeso- 
phagus (Durham).  In  the  child,  too,  the  great 
vessels  often  cross  the  trachea  higher  up  than  in 
the  adult,  and  some  inconvenience  may  also  arise 


180  SURGICAL    APPLIED    ANATOMY       [Part  I 

from  an  unduly  prominent  thymus.  In  one  case, 
in  an  infant,  the  end  of  a  tracheotomy  tube  press- 
ing on  the  front  of  the  trachea  produced  an  ulcer 
that  opened  the  innominate  artery  (Brit.  Med. 
Jour.,  1885).  In  introducing  the  cannula,  if  the 
tracheal  wound  be  missed,  it  is  easy  to  thrust  the 
instrument  into  the  lax  tissue  beneath  the  cervical 
fascia  and  imagine  that  it  is  within  the  windpipe. 

In  laryngotomy  the  air  passage  is  opened  by 
a  transverse  cut  through  the  crico-thyroid  mem- 
brane. The  crico-thyroid  space  only  measures 
about  |  an  inch  in  vertical  height  in  well- 
developed  adult  subjects,  while  in  children  it  is 
much  too  small  to  allow  of  a  cannula  being  in- 
troduced. The  crico-thyroid  arteries  cross  the 
space,  and  can  hardly  escape  division.  They  are, 
as  a  rule,  of  very  insignificant  size,  and  give  no 
trouble.  Occasionally,  however,  these  vessels  are 
large,  and  "  cases  are  recorded  in  which  serious 
and  even  fatal  haemorrhage  has  occurred  from 
these  vessels ;;  (Durham).  In  introducing  the 
cannula  it  may  readily  slip  between  the  crico- 
thyroid membrane  and  the  mucous  lining  instead 
of  entering  the  trachea. 

Foreign  bodies  often  find  their  way  into 
the  air  passages,  and  have  been  represented  by 
articles  of  food,  teeth,  pills,  buttons,  small  stones, 
and  the  like.  They  are  usually  inspired  during 
the  act  of  respiration,  and  may  lodge  in  the 
superior  aperture  of  the  larynx,  or  in  the  rima, 
or  find  their  way  into  the  ventricle,  or  lodge  in 
the  trachea,  or  enter  a  bronchus.  If  a  foreign 
substance  enters  a  bronchus  it  usually  selects 
the  right,  that  bronchus  having  its  aperture  more 
immediately  under  the  centre  of  the  trachea  than 
has  the  left  tube.  On  one  occasion,  in  a  dissecting- 
room  subject,  I  found  two  threepenny  pieces  lying 
side  by  side,  in  the  right  bronchus,  so  as  to  en- 
tirely block  the  tube.  The  danger  of  inhaled 
foreign  substances  depends  not  so  much  upon  the 
mechanical  obstruction  they  offer,  as  upon  the 
spasm  of  the  glottis  they  excite  by  reflex  irrita- 


Chap.  IX]  THE   NECK  181 

tion.  A  body  may,  however,  lodge  in  the  ventricle 
for  some  time  without  causing  much  trouble,  as 
in  a  case  reported  by  Desault,  where  a  cherry- 
stone lodged  for  fcwo  years  in  this  cavity  without 
much  inconvenience  to  its  host.  In  one  strange 
case  a  bronchial  gland  found  its  way  into  the 
trachea  by  producing  ulceration  of  that  tube,  was 
coughed  up,  and  became  impacted  in  the  rima 
glottidis.  The  patient  was  saved  from  immediate 
suffocation  by  tracheotomy.  Foreign  bodies  have 
been  removed  from  the  right  bronchus  through  a 
tracheotomy  wound.  In  this  way  MacCormac 
removed  from  the  bronchus  the  blade  of  a  tooth 
forceps. 

The  thyroid  body.— Each  lobe  should  mea- 
sure about  2  inches  in  length,  about  1^  inches  in 
breadth,  and  §  of  an  inch  in  thickness  at  its 
largest  part.  When  distinctly  beyond  these 
measurements  the  thyroid  may  be  considered  to 
be  enlarged.  Its  usual  weight  is  between  one  and 
two  ounces.  Of  its  three  surfaces,  the  _  anterior 
is  covered  by  the  infrahyoid  muscles,^  its  inner 
rests  on  the  larynx  and  trachea,  while  its  outer 
or  posterior  covers  the  carotid  sheath.  Its  promi- 
nent posterior  border  is  in  contact  at  its  lower 
part  with  the  recurrent  laryngeal  nerve  and 
oesophagus.  Each  lobe  extends  from  about  the 
middle  of  the  thyroid  cartilage  to  the  sixth  ring 
of  the  trachea.  It  is  larger  in  females  than  in 
males,  and  the  right  lobe  is  usually  larger  than 
the  left.  In  connection  with  these  matters  it  may 
be  noted  that  thyroid  enlargements  (bronchocele, 
goitre)  are  more  common  in  females  than  in 
males,  and  in  any  case  are  more  apt  to  be  first 
noticed  on  the  right  side.  The  body  being  closely 
adherent  to  the  trachea  and  larynx,  it  follows 
that  it  moves  up  and  down  during  deglutition, 
and  this  circumstance  is  of  the  utmost  value  in 
the  diagnosis  of  bronchocele  from  other  cervical 
tumours.  A  strong  process  of  cervical  fascia  (the 
suspensory  ligament  of  Berry)  binds  the  gland  to 
each  side  of  the  cricoid  cartilage,   and  has  to  be 


182  SUEGICAL    APPLIED    ANATOMY       [Fart  I 

severed  before  complete  removal  is  possible.  The 
thyroid  when  enlarged  may  distort  and  narrow 
the  trachea,  and  this  is  all  the  more  likely  to  be 
the  case  when  the  enlargement  occurs  rapidly, 
since  the  body  is  held  down  by  the  sterno-hyoid, 
sterno-thyroid,  and  omo-hyoid  muscles.  The  en- 
larged gland  is  apt  to  press  especially  upon  the 
veins  of  the  neck,  producing  engorgement  of  the 
face  and  head,  upon  the  sterno-mastoid  muscle, 
and  the  other  muscles  named,  upon  the  cervical 
nerves,  and  particularly  the  recurrent  laryngeal. 
In  some  cases  of  dyspnoea  produced  by  rapidly 
growing  bronchoceles,  Bonnet  has  proposed  sub- 
cutaneous section  of  the  muscles.  Since  the  isth- 
mus must  bind  together  the  enlarging  lobes  of  a 
bronchocele,  Sir  Duncan  Gibb,  on  the  other  hand, 
proposed  to  divide  the  isthmus  in  cases  where 
dyspnoea  resulted.  This  operation  he  performed 
several  times  with  great  relief  to  the  patient. 
The  posterior  or  outer  surface  of  the  thyroid  body 
being  in  contact  with  the  sheath  of  the  great  ves- 
sels, it  follows  that  the  gland  when  enlarged  may 
readily  receive  pulsations  from  those  vessels.  It 
generally  touches  also  the  lower  part  of  the 
pharynx,  and  the  upper  part  of  the  gullet  behind, 
and  enlargement  in  this  direction  may,  in  con- 
nection with  the  interference  with  the  movement 
of  the  larynx  in  deglutition,  serve  to  explain  the 
difficulty  in  swallowing  often  noticed  in  broncho- 
cele. 

The  isthmus  of  the  thyroid  gland  is  developed 
from  a  diverticulum  which  is  protruded  from  the 
ventral  wall  of  the  pharynx  in  the  embryo  between 
the  mandibular  and  hyoid  parts  of  the  tongue. 
The  foramen  csecum  of  the  tongue  represents  the 
point  at  which  the  diverticulum  grew  out  from 
the  pharynx.  From  this  foramen  a  duct  (the 
thyro-glossal)  may  be  found  to  lead  to  accessory 
gland  masses  about  the  hyoid  bone.  In  the  vicinity 
of  this  bone  accessory  glands  and  small  cysts  lined 
with  epithelium  are  not  unfrequently  met  with. 
These  glands,  together  with  the  so-called  pyramid 


Chap.  IX]  THE   NECK  183 

or  middle  lobe,  are  the  remains  of  the  neck  of  the 
primitive  diverticulum.  The  pyramid,  which  is 
nearly  always  connected  to  the  hyoid  bone  by  the 
levator  fchyroideae,  exists  in  79  per  cent,  of  the 
subjects  examined  (Streckeisen).  The  lateral 
lobes  are  developed  from  the  fourth  visceral  clefts. 
The  median  diverticulum  occasionally  fails  to 
join  one  of  the  lateral,  in  which  case  the  isthmus 
is  partially  absent.  Small  accessory  thyroid 
bodies  are   frequently   present. 

The  parathyroid  bodies  appear  to  play  an 
essential  part  in  the  function  of  the  thyroid. 
They  are  of  the  size  of  small  peas,  and  have  a 
structure  similar  to  that  of  the  suprarenal  bodies. 
Two  are  usually  found  on  each  side,  one  at  the 
lower  pole  of  the  lateral  lobe,  the  other  behind 
the  lobe  amongst  the  terminal  branches  of  the 
inferior  thyroid  artery.  Parathyroid  bodies  be- 
come less  numerous  as  age  advances,  so  that  in  the 
aged  none  may  be  found  (Forsyth). 

Atrophy  of  the  thyroid  gland,  or  its  destruc- 
tion by  disease,  is  apt  to  lead  to  a  general  con- 
dition of  the  body  known  as  myxozdema.  The  con- 
dition closely  resembles  cretinism,  especially  as 
met  with  in  goitrous  subjects.  Myxcedema  may 
follow  the  entire  excision  of  the  gland  by  opera- 
tion, and  has  been  produced  in  monkeys  by  ex- 
perimental removal  of  the  same.  One  prominent 
feature  in  myxcedema  is  the  swelling  of  the  sub- 
cutaneous tissues  from  an  accumulation  therein 
of   a  mucinoid   substance. 

Vasomotor  nerves  reach  the  thyroid  through 
the  lower  part  of  the  cervical  sympathetic  chain, 
and  by  the  same  course  nerves  pass  upwards  to 
the  eye.  These  nerves  appear  to  be  connected  cen- 
trally^ probably  in  the  medulla,  for  in  certain 
conditions  enlargement  of  the  thyroid  is  accom- 
panied by  protrusion  of  the  eye  (exophthalmic 
goitre).  The  lymphatics  of  the  thyroid  are 
numerous,  and  pass  to  the  deep  cervical  and 
superior    mediastinal    lymph    glands. 

In  excision  of  the  thyroid  gland  a  Y-shaped 


184  SURGICAL    APPLIED    ANATOMY      [Part  I 

median  cut  is  usually  made  that  divides  the  skin, 
fascia,  platysma,  and  anterior  jugular  veins. 
The  sternohyoid,  sterno-thyroid,  omo-hyoid,  and 
portion  of  the  sterno-mastoid  have  usually  to  be 
divided.  The  tumour  is  carefully  separated.  The 
capsule  that  invests  the  vascular  gland  must  not 
be  torn  through.  The  thyroid  vessels  are  liga- 
tured in  situ  before  the  removal  of  the  mass.  The 
superior  thyroid  reaches  the  gland  at  the  apex 
of  the  lateral  lobe  and  is  there  secured.  The  in- 
ferior thyroid  artery  enters  the  lower  part  of  the 
lobe  at  its  posterior  #  aspect.  In  securing  this 
vessel,  and  in  liberating  the  lower  part  of  the 
tumour,  the  recurrent  laryngeal  nerve  is  in  great 
danger  of  being  damaged.  The  thyroidea  ima 
artery,  an  extra  vessel  to  the  thyroid  body, 
usually  arises  from  the  innominate,  and  is  found 
in   one  subject  out  of  every  ten. 

The  gullet  commences  opposite  the  sixth 
cervical  vertebra,  and  pierces  the  diaphragm 
opposite  the  tenth  dorsal  vertebra.  The  point  is 
marked  on  the  back  by  the  overlapping  spine  of 
the  ninth  dorsal  vertebra.  By  placing  the  stetho- 
scope a  little  to  the  left  of  this  spine,  fluid  may 
be  heard  to  enter  the  stomach.  It  presents  three 
curves  :  one  is  antero-posterior,  and  corresponds 
to  the  curve  of  the  spinal  column ;  the  other  two 
are  lateral.  The  gullet,  commencing  at  the  middle 
line,  deviates  slightly  to  the  left  as  far  as  the 
root  of  the  neck ;  from  thence  to  the  fifth  dorsal 
vertebra  it  gradually  returns  to  the  middle  line, 
and  finally  it  turns  again  to  the  left,  at  the  same 
time  passing  forwards,  to  pierce  the  diaphragm. 
Its  length  is  from  9  to  10  inches.  Its  transverse 
diameter  has  been  carefully  estimated  by  Dr. 
Mouton,  by  filling  the  gullet  with  plaster-of-Paris 
in^  situ,  and  then  measuring  the  cast  thus  ob- 
tained. Dr.  Mouton  found  that  there  were  three 
narrow  parts  in  the  gullet,  one  at  its  commence- 
ment, one  about  2|  inches  from  that  point,  and 
a  third  where  the  tube  passes  through  the  dia- 
phragm.    The  diameter  at  each  of  these  points  was 


Chap.  IX]  THE    NECK  185 

a  little  over  |  an  inch  (14  mm.);  the  diameter  else- 
where was  about  f  of  an  inch  (17  mm.  to  21  mm.)- 
Bv  forcible  distension  the  two  upper  narrow  parts 
could  be  distended  to  a  diameter  of  18  to  19  mm., 
the  lower  part  to  2b  mm.,  and  the  rest  of  the  gul- 
let to  a  diameter  of  nearly  lh  inches  (35  mm.). 
It  follows  that  foreign  bodies  when  swallowed 
are  most  apt  to  lodge  either  at  the  commence- 
ment of  the  gullet  or  at  the  spot  where  it  passes 
through  the  diaphragm.  The  same  parts  also  are 
those  most  apt  to  show  the  effects  of  corrosives  that 
have   been   swallowed. 

Among  the  relations  of  the  oesophagus,  the 
following  may  be  noted  as  receiving  illustration 
in  surgical  practice  :  The  gullet  is  in  nearly  all 
its  course  in  close  relation  with  the  front  of 
the  vertebral  column.  In  the  neck  the  trachea 
is  immediately  in  front  of  it.  In  the  thorax 
it  has  the  left  bronchus,  left  bronchial  glands, 
pericardium,  and  left  auricle  in  front  of  it,  while 
the  two  vagi  form  a  plexus  on  it.  The  left 
bronchial  glands,  when  enlarged,  may  press  on  the 
gullet,  adhere  to  it,  or  even  cause  localised  soften- 
ing and  diverticula  to  spring  from  it.  The 
thoracic  duct  passes  behind  to  reach  the  left  side 
of  the  gullet  in  the  upper  part  of  the  thorax, 
while  in  the  lower  part  the  aorta,  at  first  to  the 
left  of  the  oesophagus,  gradually  becomes  pos- 
terior to  it.  It  is,  moreover,  partly  in  contact 
with  both  pleurae,  but  more  especially  with  the 
membrane  of  the  right  side ;  and,  lastly,  the  re- 
current laryngeal  nerve  ascends  between  it  and 
the  trachea.    (See  Figs.  39  and  69,  pp.  218  and  414.) 

Now,  foreign  bodies  impacted  in  the  gullet  are 
very  apt  to  lead  to  ulcerations  that  may  open 
adjacent  parts.  Thus,  in  the  Musee  Dupuytren  is 
a  specimen  showing  a  five-franc  piece  that  had 
stuck  in  the  gullet,  and  had  produced  an  ulcer 
that  had  opened  the  aorta.  In  another  instance 
a  "  smasher  "  swallowed  a  counterfeit  half-crown 
piece.  Eight  months  afterwards  he  died  of 
haemorrhage.     The    coin    had    sloughed    into    his 


186  SURGICAL    APPLIED    ANATOMY       [Part  I 

aorta.  In  another  case  (Lancet,  1871),  a  fish-bone, 
lodged  in  the  gullet  opposite  the  fourth  dorsal 
vertebra,  had  caused  two  perforating  ulcers ;  one 
on  the  right  side  had  caused  plugging  of  the  vena 
azygos  major,  while  the  other  on  the  left  had  made 
a  hole  in  the  aorta.  Less  frequently  impacted 
foreign  substances  have  found  their  way  into  the 
trachea  and  into  the  posterior  mediastinum.  Dr. 
Ogle  reports  a  case  {Path.  Soc.  Trans.,  vol.  iv. ) 
where  a  piece  of  bone  impacted  in  the  gullet 
induced  ulceration  of  an  intervertebral  disc  and 
subsequent  disease  of  the  spinal  cord.  Carcinoma 
of  the  gullet,  also,  when  it  spreads,  is  apt  to 
invade  adjacent  parts,  and  especially  to  open  into 
the  trachea  or  bronchi.  If  it  spreads  to  the 
pleura,  it  will  usually  involve  the  right  pleura, 
as  being  the  membrane  more  in  relation  with  the 
gullet.  Cancer  of  the  gullet  has  so  spread  as  to 
invade  the  thyroid  body,  the  pericardium,  and 
the  lung,  and  has  opened  up  the  first  intercostal 
artery  in  one  case  and  the  right  subclavian  in 
another  (Butlin's  "  Sarcoma  and  Carcinoma/' 
1882). 

The  sensory  nerve  supply  of  the  oesophagus 
comes  mainly  from  the  fifth  dorsal  segment  of  the 
cord  (Head).  In  cases  of  cancer  or  burns  of  the 
gullet,  pain  is  referred  to  the  skin  of  this  seg- 
ment (see  Fig.  56,  p.  333). 

(Esophageal  malformations. — In  the  newly 
born  the  upper  part  of  the  oesophagus  may  end 
blindly,  while  the  lower  part  commences  by  an 
opening  in  or  near  the  bifurcation  of  the  trachea, 
so  that  milk  can  only  reach  the  stomach  by  first 
passing  into  the  larynx  and  trachea.  Death  soon 
follows  from  suffocation  or  septic  pneumonia. 
The  condition  is  the  result  of  a  maldevelopment 
of  the  septum  between  the  trachea  and  oesophagus. 
Hernial  diverticula  of  the  mucous  membrane  occa- 
sionally occur  at  the  junction  of  the  oesophagus 
and  pharynx.  They  are  usually  named  pharyngeal 
pouches,  and  protrude  between  the  lower  border 
of  the  inferior  constrictor  and  commencement  of 


Chap.  IX]  THE  NEfitv  187 

the  oesophageal  musculature,  opposite  the  cricoid 
cartilage.  Since  the  pouch  lies  against  the  spine, 
it  necessarily  compresses  the  commencement  of  the 
oesophagus  when  it  becomes  filled  with  food. 

The  operation  of  «rsopliagotoniy  consists 
in  incising  the  gullet  for  the  purpose  of  removing 
an  impacted  foreign  body.  The  gullet  is  usually 
reached  from  the  left  side,  since  it  projects  more 
on  that  aspect.  The  incision  is  made  between  the 
sterno-mastoid  and  the  trachea,  in  the  same  direc- 
tion as  the  incision  for  ligaturing  the  common 
carotid.  The  cut  extends  from  the_  top  of  the 
thyroid  cartilage  to  the  sterno-clavicular  joint. 
The  omo-hyoid  muscle  is  drawn  outwards,  or  cut. 
The  great  vessels,  larynx,  and  thyroid  gland  are 
drawn  aside,  and  care  must  be  taken  not  to  wound 
these  structures  nor  damage  the  thyroid  vessels, 
thoracic  duct,  or  the  recurrent  nerve.  The  gullet, 
when  exposed,  is  opened  by  a  vertical  incision. 

Oreat    vessels. — The    course,    relations,    and 
abnormalities    of    the    great    cervical    vessels,    to- 
gether with  the  operations  whereby  they  may  be 
ligatured,    and    the    details    pertaining    to    those 
procedures,  are  so  fully  given,  not  only  in  works 
on  operative  surgery,  but  also  in  the  chief  ana- 
tomical text-books,  that  nothing  need  be  said  upon 
the  matter  in  this  place.     The  bifurcation  of  the 
common  carotid  is  a  favourite  locality  for  aneur- 
ism, being  a  point  where  some  resistance  is  offered 
to   the  blood   current.     These   tumours,    also,    are 
common  at  the  root  of  the  neck,   where  they  are 
often  due  to  extension  of  aneurismal  disease  from 
the  aorta,  although  in  many  cases  they  have  an  in- 
dependent origin.     It  is  in  the  neck  that  the  treat- 
ment of  aneurism  by  the   distal  ligature  is  most 
often  carried  out.     There  is  no  place  in  the  body 
where  Brasdor's  operation  can  be  carried  out  with 
the   completeness   with   which   it  can   be   adopted 
in  the  neck.     In  this  procedure  a  main  trunk  is 
ligatured  on  the   distal  side  of  an  aneurism,   no 
branches  intervening  between  the  sac  and  the  liga- 
ture.    The  cure  by  this  measure  depends  upon  the 


188  SURGICAL    APPLIED    ANATOMY       [Part  I 

fact  that  blood  does  not  continue  to  go  to  parts 
when  once  the  need  for  blood  in  them  is  dimin- 
ished. Thus,  after  amputation  at  the  hip  joint, 
the  femoral  artery,  having  no  need  to  carry  to 
the  stump  the  amount  of  blood  it  brought  to  the 
limb,  often  shrinks  to  a  vessel  no  larger  than 
the  radial.  When  an  aneurism  low  down  in  the 
carotid  artery  is  treated  by  ligature  of  the  vessel 
near  its  bifurcation  by  Brasdor's  method,  the 
blood,  having  now,  as  it  were,  no  object  in  enter- 
ing the  carotid  trunk,  soon  ceases  to  fill  the 
vessel  entirely,  and  the  artery  (and  in  successful 
cases  the  aneurism)  shrinks  in  consequence. 
Wardrop's  operation,  or  the  distal  ligature  of 
large  branches  for  the  relief  of  aneurism  of  a  main 
trunk,  is  now,  perhaps,  quite  limited  as  to  its 
performance  to  the  ligature  of  the  carotid  and 
subclavian  arteries  for  innominate  aneurism. 
Since  in  this  procedure  large  branches  come  off  be- 
tween the  sac  and  the  ligature,  it  is  not  easy  to 
fully  understand  how  the  operation  acts  bene- 
ficially. It  is  assumed  to  owe  its  success  to  the 
same  principle  that  underlies  Brasdor's  operation. 
The  right  carotid  and  subclavian  have  also  been 
ligatured  for  aortic  aneurism  with  some  success, 
and  here  also  the  reason  for  the  good  effected  by 
the  operation  is  difficult  to  appreciate.  It  has 
been  pointed  out  that  the  innominate  artery  lies 
more  or  less  directly  in  the  axis  of  the  ascending 
aorta,  while  the  left  carotid  and_  subclavian 
arteries  arise  at  an  angle  to  that  axis,  and  it  is 
upon  this  fact  that  reasons  have  been  founded  for 
selecting  the  vessels  of  the  right  side  (Barwell). 
The  matter  is,  however,  complicated  by  the  know- 
ledge that  when  vegetations  are  swept  off  the 
aortic  valves  they  enter  the  left  carotid  with  in- 
finitely greater  frequency  than  they  do  the  right. 
The  whole  subject,  indeed,  requires  investigation. 
The  cervical  connective  tissue  being  lax,  aneur- 
isms in  this  part  can  grow  and  spread  rapidly, 
and  usually  soon  produce  "  pressure  symptoms." 
As  examples  of  these  may  be  noted  oedema  and 


Chap.  IX]  THE   NECK  189 

lividity  of  the  face  and  of  the  upper  limb  from 
pressure  upon  the  main  veins,  laryngeal  symptoms 
from  pressure  upon  the  recurrent  nerve  or  trachea, 
spasm  of  the  diaphragm  from  pressure  upon  the 
phrenic  nerve,  damage  to  the  sympathetic,  and 
giddiness  and  impaired  vision  from  anaemia  of 
the  brain. 

The  vertebral  artery  has  been  ligatured  with 
doubtful  benefit  in  cases  of  epilepsy.  It  is  sur- 
rounded by  vasomotor  nerves  derived  from  the 
inferior  cervical  ganglion,  which  also  are  neces- 
sarily tied.  The  artery  is  reached  through  an  in- 
cision made  along  the  posterior  border  of  the 
sterno-mastoid  muscle  just  above  the  clavicle.  The 
"  carotid  tubercle  "  {see  p.  158)  is  then  sought 
for,  and  vertically  below  it  lies  the  artery,  in 
the  gap  between  the  scalenus  anticus  and  longus 
colli  muscles.  The  procedure  is  surrounded  with 
considerable  difficulties. 

In  cases  of  bleeding  from  branches  of  the  ex- 
ternal carotid  it  is  better,  when  possible,  to  liga- 
ture the  trunk  of  that  vessel  in  preference  to  se- 
curing the  common  carotid.  The  latter  procedure 
has  a  high  death-rate  (50  per  cent.),  due  (1)  to 
brain  mischief,  following  the  lessened  blood- 
stream through  the  internal  carotid,  and  (2)  to 
secondary  haemorrhage,  due  to  the  very  free  ana- 
stomosing channels. 

Air  in  veins. — The  veins  of  the  neck  are 
under  the  influence  of  the  respiratory  movements. 
The  veins  do  not  collapse  owing  to  attachments  to 
the  surrounding  fasciae.  During  inspiration  these 
vessels  become  more  or  less  emptied;  during  ex- 
piration they  become  enlarged  and  turgid.  With 
greatly  impeded  breathing  they  may  attain  for- 
midable size.  Since  ether  usually  causes  some 
respiratory  difficulty,  it  is  seldom  administered 
in  operations  on  the  neck.  The  only  other  veins 
that  are  under  the  influence  of  the  aspiratory 
power  of  the  thorax  are  the  axillary  vein  and 
its  larger  tributaries.  When  any  one  of  these 
vessels    is    wounded,    and   the    wound    is    for    the 


190 


SURGICAL    APPLIED    ANATOMY       [Part  I 


moment  dry,  air  may  very  readily  be  drawn  into 
it  during  the  inspiratory  act,  just  as  air  is  drawn 


Fig.  35.— Showing  the  position  of  the  lymphatic  glands  of  the  head  and 
neck.  The  outlines  of  the  sterno-mastoid  (s.m.),  trapezius  (tr.  ), 
internal  jugular,  subclavian,  and  right  innominate  veins  are  shown. 

1,  Submaxillary  glands,  1'  area  drained ;  2,  suprahyoid  glands,  2'  area  drained : 
3,  parotid  glands,  3' area  drained;  4,  postauricular  glands,  4'  area  drained; 
5,  occipital  glands,  5'  area  drained  ;  C,  in  front  of  external  jugular  vein,  marking 
position  of  the  superficial  cervical  glands ;  7,  laryngeal  gland ;  8,  8,  8,  upper 
deep  cervical  glands;  9,9,9,  lower  deep  cervical  glands;  10  gland  receiving 
lymph  from  thyroid  ;  11,  superior  mediastinal  glands ;  12,  axillary  glands. 


Chap.  IX]  THE    NECK  191 

into  the  trachea.     The  air  causes  embolism  of  the 
pulmonary   capillaries. 

Valves  in  the  veins  of  the  neck. — The  sub- 
clavian veins  and  their  tributaries  are  liberally 
provided  with  valves,  but  the  internal  jugular  has 
only  one  pair,  situated  at  its  termination  in  the 
innominate  vein.  There  are  no  valves  in  the  in- 
nominate veins  nor  in  the  superior  vena  cava. 
When  the  venous  pressure  within  the^  thorax  is 
greatly  raised,  as  in  lifting  heavy  weights,  only 
the  terminal  valves  of  the  internal  jugular  vein 
prevent  the  transmission  of  the  pressure  to  the 
brain.  In  accidents  which  cause  sudden  compres- 
sion of  the  thorax,  the  head  and  neck  may  remain 
livid  for  days  following  the  accident.  The 
lividity  is  probably  due  to  the  jugular  valves 
yielding,  thus  subjecting  the  capillaries  of  the 
head  and  neck  to  a  higher  pressure  than  they  are 
able  to  withstand. 

The  lymphatic  glands  of  the  head  and 
neck  are  numerous,  and  arranged  in  the  follow- 
ing sets   (Fig.   35)  : — 

(1)  Submaxillary  glands,  10  to  15  in  number, 
situated  at  the  lower  border  of  the  jaw  beneath 
the  cervical  fascia ;  (2)  the  suprahyoid,  1  or  2 
in  number,  situated  between  the  chin  and  hyoid 
bone  near  the  middle  line;  (3)  parotid  or  pre- 
auricular set,  situated  in  and  over  the  parotid 
gland ;  (4)  postauricular,  or  mastoid,  2  to  4  in 
number,  situated  over  the  mastoid  process;  (5) 
occipital,  3  to  5  in  number,  over  the  insertion 
of  the  complexus  muscle  ;  (6)  superficial  cervical 
glands,  often  absent,  situated  over  the  sterno- 
mastoid  along  the  ^  external  jugular  vein;  (7) 
laryngeal,  1  to  3  in  number,  below  the  great 
horn  of  the  hyoid ;  (8)_  the  upper  deep  cervical  set, 
10  to  20  in  number,  situated  over  the  upper  part 
of  the  internal  jugular  vein  and  bifurcation  of  the 
common  carotid  artery ;  (9)  lower  deep  cervical 
set,  surrounding  the  terminal  parts  of  the  in- 
ternal jugular,  subclavian,  external  jugular,  and 
transverse     cervical     veins.       This     set    becomes 


192  SURGICAL    APPLIED    ANATOMY       [Part  I 

continuous  with  the  axillary  and  mediastinal 
glands. 

These  glands  are  very  often  enlarged  and  in- 
flamed, and  it  is  in  this  part  of  the  lymphatic 
system  that  the  changes  in  scrofula  are  most  com- 
monly met  with.  The  inflammatory  affections  in 
glands  would  appear  to  be  always  of  a  secondary 
nature  (if  we  exclude  some  cases  of  inflammation 
incited  by  injury,  and  perhaps  by  exposure  to 
severe  cold),  and  to  follow  disturbances  in  those 
parts  of  the  periphery  whence  they  respectively 
receive  their  lymph.  It  may  be  convenient,  there- 
fore, to  group  the  relations  of  certain  glands  to 
certain  parts  of  the  periphery. 

Scalp. — Posterior  part  =  occipital  and  post- 
auricular  glands.  Frontal  and  parietal  portions 
==  parotid  glands  (Fig.  35). 

Vessels  from  the  scalp  also  enter  the  super- 
ficial cervical  set  of  glands. 

Skin  of  face  and  neck  =  submaxillary,  parotid, 
and   superficial   cervical   glands. 

External  ear  =  superficial  cervical  glands. 

Lotver  lip  =  submaxillary  and  suprahyoid 
glands. 

Buccal  cavity  =  submaxillary  glands  and  deep 
cervical  glands  (upper  set). 

Gums  of  lower  jaw  =  submaxillary  glands. 

Tongue. — Anterior  portion  =  suprahyoid  and 
submaxillary  glands.  Posterior  portion  =  deep 
cervical  glands  (upper  set). 

Tonsils  and  palate  ==  deep  cervical  glands 
(upper  set). 

Pharynx. — Upper  part  =  parotid  and  retro- 
pharyngeal glands.  Lower  part  =  deep  cervical 
glands  (upper  set). 

Larynx,  orbit,  and  roof  of  mouth  =  deep  cer- 
vical glands  (upper  set). 

Nasal  fossce  —  retropharyngeal  glands,  deep 
cervical  glands  (upper  set).  Some  lymphatics 
from  the  posterior  part  of  the  fossae  enter  the 
parotid  glands.*" 

*  From  "Scrofula,  and  its  Gland  Diseases,"  by  the  Author. 


Chap.  IX]  THE    NECK  193 

In  the  removal  of  the  deep  cervical  glands 
a  number  of  structures  are  liable  to  be  wounded. 
The  glands  frequently  become  firmly  adherent  to 
the  internal  jugular  vein;  the  uppermost  glands 
surround  the  spinal  accessory  nerve ;  the  super- 
ficial cervical  nerves  pass  among  those  of  the 
lower  deep  cervical  set ;  the  thoracic  duct  has  been 
wounded  in  removing  glands  from  the  left  supra- 
clavicular fossa. 

Thoracic  duct  in  the  neck. — A  point  taken 
on  the  upper  border  of  the  clavicle,  1  inch  from 
its  sternal  end,  will  mark  the  angle  between  the 
internal  jugular  and  subclavian  veins  where  the 
thoracic  duct  ends.  At  its  termination  the  duct 
curves  outwards  over  the  scalenus  anticus  and 
phrenic  nerve  above  its  point  of  entrance  where 
it  is  furnished  with  valves.  It  may  be  double 
or  triple  at  its  termination.  Ligature  of  the  duct 
is  followed  by  no  untoward  symptoms,  as  a  rule, 
a  result  which  is  due  to  the  free  anastomosis  which 
exists  between  it  and  the  lymphatics  of  the  right 
side  of  the  thorax  and  to  communications  with 
the  azygos  veins  (Leaf). 

Branchial  nstiihr. — Certain  congenital  fis- 
tula? are  sometimes  met  with  in  the  neck,  which 
are  due  to  partial  persistence  of  one  of  the 
branchial  clefts.  These  clefts  are  placed  in  the 
foetus  between  the  branchial  arches.  The  arches 
are  usually  described  as  five  in  number.  The 
first  lays  the  foundation  for  the  lower  jaw  and 
malleus.  From  the  second  are  developed  the 
styloid  process,  the  stylo-hyoid  ligament,  and 
lesser  cornu  of  the  hyoid  bone.  From  the  third  are 
formed  the  body  and  greater  cornu  of  the  hyoid 
bone,  while  the  fourth  and  fifth  take  part  in  the 
formation  of  the  soft  parts  of  the  neck  below  the 
hyoid  bone.  The  first  cleft  is  between  the  first  and 
second  arches.  "  The  cervical  branchial  fistulse 
appear  as  very  fine  canals  opening  into  minute 
orifices  in  one  or  both  sides  of  the  fore  part  of 
the  neck  and  leading  backwards  and  inwards  or 
backwards  and  upwards  towards  the  pharynx  or 
N 


194  SURGICAL    APPLIED    ANATOMY       [Part  I 

oesophagus  ';  (Paget).  Their  length  is  about  lj  to 
2£  inches,  and  their  diameter  varies  from  that  of 
a"  bristle  to  that  of  an  ordinary  probe.  They 
usually  exist  about  the  line  of  the  third  or  fourth 
cleft,  and  are  most  often  met  with  just  above  the 
sterno-clavicular  joint.  Others  are  found  about 
the  level  of  the  top  of  the  thyroid  cartilage  at  the 
anterior  edge  of  the  sterno-mastoid  muscle.  About 
some  of  these  fistulse,  or  in  spots  where  they  com- 
monly open,  flat  pieces  of  cartilage  may  be  found. 
The  more  prominent  of  these  have  been^  termed 
supernumerary  auricles.  Certain  dermoid  cysts 
of  the  neck  arise  from  unobliterated  branchial 
spaces,  and  it  would  appear  also,  that  certain 
polycystic  congenital  tumours,  occurring  as  one 
form  of  "  hydrocele  of  the  neck,;J  may  be  de- 
veloped from  an  imperfectly  closed  cleft.  I  have 
elsewhere  detailed  the  dissection  of  one  of  these 
tumours  that  appeared  to  be  associated  with  a 
partially  closed  second  branchial  cleft  (Path. 
Soc.   Trans.,   1881). 

His  has  shown  that  many  branchial  fistulse  and 
cysts  are  formed  from  the  cervical  sinus.  The 
cervical  sinus  is  produced  in  the  neck  of  the  em- 
bryo by  a  rapid  growth  in  the  second  and  third 
arches  which  causes  them  to  grow  backwards  and 
overlap  the  fourth  and  fifth.  The  piece  of  epiblast 
thus  included  in  the  neck  usually  disappears,  but 
it  may  persist  and  give  rise  to  a  cyst  or,  if  open, 
to  a  fistula.  The  common  fistula,  that  which  opens 
above  the  sterno-clavicular  joint,  is  derived  from 
the  cervical  sinus.  It  is  to  be  remembered  that 
the  branchial  clefts  are  only  depressions  in  the 
wall  of  the  pharynx,  not  complete  fissures.  Hence 
fistulas  rarely  communicate  with  the  pharynx. 

The  ventricle  of  the  larynx,  as  is  normally  the 
case  in  many  apes,  may  become  prolonged  into  a 
sac  which  passes  into  the  neck  through  the  thyro- 
hyoid membrane,  thus  forming  a  cervical  air 
cyst  or  sac, 


Part  II.— THE    THORAX 


CHAPTER    X 

1.  The  thoracic  walls. — The  two  sides  of  the 
chest  are  seldom  symmetrical,  the  circumference  of 
the  right  side  being  usually  the  greater,  a  fact  that 
is  supposed  to  be  explained  by  the  unequal  use 
of  the  upper  limbs.  In  Pott's  disease,  involving 
the  dorsal  region,  when  the  spine  is  much  bent 
forwards  the  thorax  becomes  greatly  deformed. 
Its  antero-posterior  diameter  is  increased,  the 
sternum  protrudes,  and  may  even  be  bent  by  the 
bending  of  the  spine,  the  ribs  are  crushed  to- 
gether, and  the  body  may  be  so  shortened  that  the 
lower  ribs  overlap  the  iliac  crest. 

In  pigeou  breast  deformity  the  sternum  and 
cartilages  are  rendered  protuberant,  so  that  the 
antero-posterior  measurement  of  the  chest  is  much 
increased,  while  a  deep  sulcus  exists  on  either 
side  along  the  line  of  junction  of  the  ribs  and 
their  cartilages.  It  is  by  the  sinking  in  of  the 
parietes  along  the  costo-chondral  junctions  that 
the  protuberance  is  produced.  In  children,  and 
especially  in  rickety  children,  the  thorax  is  very 
pliable  and  elastic,  and  if  a  constant  impediment 
exists  to  the  entrance  of  air,  as  afforded,  for 
example,  by  greatly  enlarged  tonsils,  the  thoracic 
walls  may  yield  in  time  to  the  suction  brought 
to  bear  upon  them  at  each  inspiration.  The 
weakest  part  of  the  thorax  is  along  the  costo- 
chondral  line  on  either  side,  and  it  is  here  that 

195 


196  SUKGICAL   APPLIED    ANATOMY     [Part  II 

the  parietes  yield  most  conspicuously  in  such 
cases,  and  by  this  yielding  the  deformity  is  pro- 
duced. 

Deformities  of  the  chest  result  from  abnor- 
mal curvatures  of  the  dorsal  part  of  the  spinal 
column.  The  ribs  are  firmly  bound  to  the  verte- 
brae by  the  costo-vertebral  and  costo-transverse 
ligaments,  and  hence  alteration  in  the  position  of 
vertebras  is  attended  by  changes  in  the  costal 
series.  Thus,  when  there  is  kyphosis  in  the  dorsal 
region  the  upper  part  of  the  spine  is  bent  for- 
wards and  downwards,  carrying  with  it  the 
upper  ribs  and  the  sternum.  The  antero-posterior 
diameter  of  the  thorax  is  thereby  increased,  but 
its  vertical  and  transverse  measurements  are  de- 
creased. When  lateral  curvature  is  produced  in 
the  dorsal  region,  the  ribs,  on  the  side  towards 
which  the  bend  occurs,  are  necessarily  compressed, 
while  on  the  opposite  side  they  are  separated.  In 
scoliosis  of  the  spine  not  only  is  a  lateral  curva- 
ture formed,  but  the  vertebras  undergo  a  rotation 
at  the  same  time.  The  vertebral  bodies  move  to- 
wards the  convexity  and  their  spines  towards  the 
concavity  of  the  curvature  (Fig.  36).  The  ribs  on 
the  concave  side  are  carried  forwards  on  the  trans- 
verse processes  and  their  angles  open  out,  the  side 
of  the  chest  becoming  flattened  behind.  On  the 
other  side  (convex)  the  angles  are  unduly  promi- 
nent, for  the  ribs  are  carried  backwards  at  their 
vertebral  extremities  and  bent  inwards  in  front. 
The  transverse  diameter  of  the  chest  thus  becomes 
oblique  (Fig.  36).  On  the  concave  side  the  inter- 
costal spaces  are  diminished  in  size,  the  ribs  even 
coming  into  contact,  while  on  the  convex  side 
the  spaces  are  increased  in  size.  The  thoracic 
viscera  are  necessarily  distorted  in  shape  and 
altered  in  position. 

The  sternum.— The  upper  edge  of  the  sternum 
corresponds  to  the  disc  between  the  second  and 
third  dorsal  vertebrae,  and  the  sterno-xiphoid 
joint  to  the  middle  of  the  tenth  dorsal.  In  the 
foetus  at  full  term  the  upper  edge  of  the  sternum 


Chap.  X] 


THE    THORAX 


197 


STERNUM 


AN  OLE: 

Ari<;Le 

Fig.  36.— Showing  the  changes  in  the  thorax 
which  follow  scoliosis  of  the  spine. 
(After  Redard.) 

The  convexity  of  the  spinal  curvature  is  towards 
the  right ;  on  that  side  the  ribs  are  sharply  bent 
at  their  angles.  On  the  concave  Cleft)  side  the 
ribs  have  an  open  angle. 


is  opposite  the  middle  of  the  first  dorsal  vertebra 
(Symington).  A  transverse  ridge  may  be  felt 
upon  its  anterior  surface  that-  corresponds  to  the 
junction  of  the  manubrium  and  gladiolus,  and  is 
in  a  line  with 
the  second  costal 
cartilages.  The 
skin  over  the 
sternal  region  is 
the  part  of  the 
surface  most  fre- 
quently the  seat 
of  cheloid.  The 
bone  is  rarely 
fractured,  being 
soft  and  spongy, 
and  supported  by 
the  elastic  ribs 
and  their  cartil- 
ages, as  by  a 
series  of  springs.  In  the  old,  when  the  cartilages 
are  ossified  and  the  chest  is  more  rigid,  the  tend- 
ency to  fracture  is  increased.  The  sternum  is  most 
often  found  fractured  in  connection  with  injuries 
to  the  spine,  although  it  may  be  broken  by 
simple  direct  violence.  The  bone  may  be  frac- 
tured by  violent  bending  of  the  spine  backwards, 
and  by  abrupt  bending  of  it  forwards.  In  the 
former  instance  the  lesion  is  probably  due  to 
muscular  violence,  to  the  abdominal  muscles  and 
the  sterno-mastoicl  pulling  one  against  the  other. 
In  the  latter  instance  the  lesion  is  commonly 
brought  about  by  the  violent  contact  of  the  chin 
with  the  bone.  Dislocation  may  occur  ^  at  the 
sterno-manubrial  joint.  The  manubrium  in  these 
injuries  generally  remains  in  situ,  while  the 
gladiolus  with  the  ribs  is  displaced  forwards  in 
front  of  it.  A  considerable  degree  of  respiratory 
movement  takes  place  at  this  joint;  only  in  very 
old  people  does  it  become  obliterated  by  bony 
union.  It  possesses  a  distinct  synovial  cavity 
surrounded  by  strong  fibrous  and  fibro-cartilagin- 


198  SURGICAL   APPLIED   ANATOMY     [Part  II 

ous  ligaments.  Malgaigne  cites  the  case  of  a 
youth  who,  from  constant  bending  at  his  work  as 
a  watchmaker,  caused  the  second  piece  of  the 
sternum  to  glide  backwards  behind  the  manu- 
brium. 

From  its  exposed  position  and  cancellous  struc- 
ture, the  sternum  is  liable  to  many  affections,  such 
as  caries  and  gummatous  periostitis.  The  com- 
parative softness  also  of  the  bone  is  such  that 
it  has  been  penetrated  by  a  knife  in  homicidal 
wounds.  The  shape  and  position  of  the  bone  have 
also  been  altered  by  pressure,  as  seen  sometimes 
in  artisans  following  employments  requiring  in- 
struments, etc.,  to  be  pressed  against  the  chest. 

Certain  holes  may  appear  in  the  middle  of  the 
sternum,  and  through  them  mediastinal  abscesses 
may  escape,  and  surface  abscesses  pass  deeply  into 
the  thorax.  These  holes  result  from  imperfect 
union  of  the  right  and  left  sternal  bars,  out  of 
which  the  sternum  is  formed.  In  the  case  of  E. 
Groux,  the  bone  was  separated  vertically  into  two 
parts.  The  gap  could  be  opened  by  muscular 
effort  and  the  heart  exposed,  covered  only  by  the 
soft  parts.  The  sternum  has  been  trephined  for 
mediastinal  abscess,  and  for  paracentesis  in  peri- 
cardial effusion,  and  it  has  been  proposed  also  to 
ligature  the  innominate  artery  through  a  trephine 
hole  in  the  upper  part  of  the  bone. 

The  ribs  are  placed  so  obliquely  that  the  an- 
terior end  of  one  rib  is  on  a  level  with  the  pos- 
terior end  of  a  rib  some  way  below  it  in  numerical 
order.  Thus  the  second  rib  in  front  corresponds 
to  the  fifth  rib  behind,  and  the  insertion  of  the 
seventh  to  the  tenth.  If  a  horizontal  line  be 
drawn  round  the  body  at  the  level  of  the  inferior 
angle  of  the  scapula,  while  the  arms  are  at  the 
side,  the  line  would  cut  the  sternum  in  front  at 
the  attachment  of  the  sixth  cartilage,  would  cut 
the  fifth  rib  at  the  nipple  line,  and  the  ninth  rib 
at  the  vertebral  column.  The  second  rib  is  indi- 
cated by  the  transverse  ridge  on  the  sternum 
already  alluded  to  (angulus  Ludovici).    The  lower 


Ohap.  X]  THE    THOBAX.  199 

border  of  the  pectoralis  major  leads  to  the  fifth 
rib,  and  the  first  visible  serration  of  the  serratus 
magnus  corresponds  to  the  sixth.  The  longest  rib 
is  the  seventh,  the  shortest  the  first.  The  most 
oblique  rib  is  the  ninth. 

The  ribs  are  elastic  and  much  curved,  and, 
being  attached  by  many  ligaments  behind  to  the 
column,  and  in  front  to  the  yielding  cartilages, 
resist  injuries  tending  to  produce  fracture  with 
the  qualities  possessed  by  a  spring.  A  rib  may 
be  fractured  by  indirect  violence,  as  by  a  wheel 
passing  over  the  body  when  lying  prostrate  on  the 
back.  In  such  a  case  the  force  tends  to  approxi- 
mate the  two  ends  of  the  bone,  and  to  increase  its 
curve.  When  it  breaks,  therefore,  it  breaks  at 
the  summit  of  its  principal  curve,  i.e.  about  the 
centre  of  the  bone.  The  fragments  fracture  out- 
wards, and  the  pleura  stands  no  risk  of  being 
penetrated.  When  the  rib  is  broken  by  direct 
violence,  lesion  occurs  at  the  spot  encountered  by 
the  force,  the  bone  fractures  inwards,  the  curve 
of  the  rib  tends  to  be  diminished  rather  than 
increased,  and  there  is  much  risk  of  the  fragments 
lacerating  the  pleura. 

Those  most  often  broken  are  the  sixth,  seventh, 
and  eighth,  they  being  under  ordinary  circum- 
stances the  most  exposed.  The  rib  least  frequently 
fractured  is  the  first,  which  lies  under  cover  of  the 
clavicle.  In  elderly  people  dying  from  phthisis  the 
cartilage  of  the  first  rib  is  often  found  to  be  cal- 
cified and  occasionally  to  be  fractured.  Fractures 
are  more  common  in  the  elderly  than  in  children, 
owing  to  the  ossification  of  the  cartilages  that 
takes  place  in  advancing  life.  When  a  rib  is 
fractured,  no  shortening  occurs,  the  bone  being 
fixed  both  in  front  and  behind,  while  vertical 
displacement  is  prevented  by  the  attachments  of 
the  intercostal  muscles.  Thus  no  obvious  de- 
formity is  produced  unless  a  number  of  consecu- 
tive ribs  are  the  subjects  of  fracture.  These  bones 
have  been  broken  by  muscular  violence,  as  during 
coughing,  and  in  violent  expulsive  efforts  such  as 


200  SURGICAL    APPLIED    ANATOMY     [Part  II 

are  incident  to  labour.     In  such  instances  the  ribs 
are  probably  weakened  by  atrophy  or  disease. 

In  many  instances  of  gun-shot  wound  the  curve 
of  the  rib  has  saved  the  patient's  life.  In  such 
cases  the  bullet  has  entered  behind  near  the  dorsal 
spine,  has  been  conducted  round  the  chest,  along 
the  curve  of  a  rib  beneath  the  skin,  and  has  es- 
caped again  near  the  sternum.  This  property, 
however,  of  the  ribs  for  turning  bullets  refers 
rather  to  the  days  of  round  bullets,  and  not  to 
modern  conical  projectiles. 

In  rickets  changes  take  place  at  the  point  of 
junction  of  the  ribs  and  cartilages  leading  to 
bony  elevations,  which  produce,  when  the  ribs  on 
both  sides  are  affected,  the  condition  known  as  the 
"  rickety  rosary.' ; 

The  intercostal  spaces  are  wider  in  front 
(than  behind,  and  between  the  upper  than  the 
lower  ribs.  The  widest  of  the  spaces  is  the  third, 
then  the_  second,  then  the  first.  The  seventh, 
eighth,  ninth,  and  tenth  interspaces  are  very  nar- 
row in  front  of  the  angles  of  the  ribs.  The  first 
five  spaces  are  wide  enough  to  admit  the  whole 
breadth  of  the  index  finger.  The  spaces  are 
widened  in_  inspiration,  narrowed  in  expiration, 
and  can  be  increased  in  width  by  bending  the  body 
over  to  the  opposite  side. 

1 ,  Paracentesis  is  usually  performed  in  the 
/sixth  or  seventh  space,  at  a  point  midway  between 
//the  sternum  and  the  spine,  or  midway  between  the 
/  anterior  and  posterior  axillary  lines.  The  seventh 
space  can  be  readily  identified  by  its  relation- 
ship to  the  angle  of  the  scapula;  when  the  arm  is 
by  the  side  of  the  body  this  space  is  slightly  over- 
lappedby  the  angle.  If  a  lower  space  be  selected 
there _  is  danger  of  wounding  the  diaphragm, 
especially  upon  the  right  side.  If  the  eighth  or 
ninth  space  be  selected  the  incision  is  made  just 
externally  to  the  line  of  the  angle  of  the  scapula. 
The  trochar  should  be  entered  during  inspiration, 
the  space  being  widened  thereby,  and  should  be 
kept  as  near  as  possible  to  the  lower  border  of  the 


Chap.  X]  THE    THORAX  2C1 

space,  so  as  to  avoid  the  intercostal  vessels.  Tap- 
ping of  the  chest  through  any  space  posterior 
to  the  angles  of  the  ribs  is  not  practicable,  owing 
to  the  thick  covering  of  muscles  upon  the  thoracic 
wall  in  this  place,  and  the  fact  that  the  inter- 
costal artery,  having  a  more  horizontal  course 
than  the  corresponding  ribs,  crosses  the  middle 
of  this  part  of  the  space  obliquely.  Beyond  the 
angle  the  intercostal  vessels  lie  in  a  groove  on  the 
inferior  border  of  the  rib  forming  ^  the  upper 
boundary  of  the  space.  The  vein  lies  immediately 
above  the  artery,  and  the  nerve  immediately  below 
it.  In  the  upper  four  or  five  spaces,  however,  the 
nerve  is  at  first  higher  than  the  artery.  Paracen- 
tesis of  the  thorax  is  occasionally  followed  by  syn- 
cope or  even  death.  It  is  difficult  to  account  for 
such  a  result ;  it  may  be  a  reflex  inhibition  of  the 
heart  set  up  during  perforation  of  the  parietal 
pleura,  which  is  richly  supplied  by  the  intercostal 
nerves,  or  by  injury  to  the  lung,  which  is  supplied 
by  the  vagus. 

Pus  may  readily  be  conducted  along  the  loose 
tissue  between  the  two  layers  of  intercostal  mus- 
cles. Thus,  in  suppuration  following  upon  disease 
of  the  vertebrae,  or  of  the  posterior  parts  of  the 
ribs,  the  pus  may  be  conducted  along  the  inter- 
costal spaces  to  the  sternum,  and  may  thus  pre- 
sent at  a  considerable  distance  from  the  real  seat 
of  the  disease. 

Removal  of  ribs.  —  In  order  to  obtain  a 
free  opening  into  the  pleural  cavity  a  portion  of 
one  or  even  two  ribs  may  be  excised. 

In  some  cases  of  long-standing  empyema  with  an 
open  sinus,  all  that  part  of  the  bony  wall  of  the 
thorax  wThich  corresponds  to  the  outer  boundary 
of  the  suppurating  cavity  is  removed  in  order  that 
the  cavity  may  collapse  and  be  in  a  position  to 
close.  This  latter  measure  is  known  as  Estlander's 
operation,  or  thoracoplasty.  In  some  instances 
portions  of  as  many  as  nine  ribs  have  been  ex- 
cised, and  the  total  length  of  bone  removed  has 
reached  50  to  60  inches. 


202  SURGICAL    APPLIED    ANATOMY     [Part  II 

In  removing  a  rib  the  bone  is  entirely  bared 
of  periosteum  with  the  rugine,  and  the  excision 
is  extraperiosteal.  In  this  way  the  intercostal 
vessels  are  not  exposed,  and,  if  divided  subse- 
quently, can  be  readily  secured  when  the  ribs 
are  out  of  the  way. 

The  internal  mammary  artery  runs  paral- 
lel to  the  border  of  the  sternum,  and  about  ^  an 
inch  from  it.  It  may  give  rise  to  rapidly  fatal 
haemorrhage  if  wounded.  The  vessel  may  readily 
be  secured  in  the  first  three  intercostal  spaces,  and 
with  some  difficulty  in  the  fourth  or  fifth  space. 
It  is  most  easily  reached  through  the  second  space, 
and  cannot  be  secured  through  any  space  below  the 
fifth. 

The  female  breast  extends  from  the  second 
rib  above  to  the  sixth  below,  and  from  the  side  of 
the  sternum  to  the  mid-axillary  line  (Stiles). 
In  cases  of  retained  lactation  the  twelve  to  fifteen 
irregular  lobes  which  make  up  the  body  of  the 
gland  can  be  felt  radiating  outwards  from  the 
nipple.  The  lactiferous  ducts,  which  correspond 
in  number  to  the  lobes,  open  at  the  apex  of  the 
nipple,  within  which  each  shows  a  dilatation  or 
ampulla.  Branching  processes  of  adjoining  lobes 
unite  and  enclose  spaces  within  the  body  of  the 
gland,  containing  connective  tissue  and  masses  of 
fat.  After  the  menopause,  when  the  glandular 
tissue  is  absorbed  in  great  part,  and  during  the 
resting  condition,  fat  forms  the  greater  part  of 
the  female  breast.  Besides  the  main  body  of  the 
gland,  Stiles  has  drawn  attention  to  numerous 
peripheral  processes  which  lie  in  the  surrounding 
connective   tissue. 

Although  the  principal  part  of  the  breast  rests 
on  the  pectoralis  major,  quite  one-third  of  the 
gland  crosses  the  outer  border  and  rests  on  the 
serratus  magnus  within  the  axilla.  It  also  covers 
the  origins  of  the  obliquus  abdominis  externus  and 
rectus  abdominis.  In  excision  or  inflammation 
of  the  breast  it  is  important  to  bind  the  arm  by 
the  side  to  keep  the  parts  from  being  disturbed 


Chap.  X]  THE    THORAX  203 

by  the  pectoralis  major.  Peripheral  processes  of 
the  gland  and  many  of  its  deep  lymphatics  enter 
the  pectoral  sheath,  hence  the  removal  of  this 
structure  with  part,  or  even  all,  of  the  pectoral 
musculature  if  complete  extirpation  of  cancer  is 
to  be  assured.  The  loose  retromammary  tissue 
which  binds  the  mamma  loosely  to  the  pectoral 
sheath  may  be  the  seat  of  abscess,  or  sometimes  of 
a  bursal  cyst. 

The  nipple,  in  the  male  and  in  the  virgin 
female,  is  situated  on  the  fourth  intercostal  space, 
about  |  of  an  inch  from  the  junction  of  the  ribs 
with  their  cartilages ;  after  lactation  the  breast 
becomes  pendent,  and  the  nipple  no  longer  serves 
as  a  guide  to  the  intercostal  spaces.  The  nipple 
contains  erectile  and  muscular  tissue,  and_  is 
richly  supplied  by  cutaneous  branches  ofthe  third 
and  fourth  spinal  nerves.  The  skin  is  pigmented, 
thin  and  sensitive,  and  often  the  seat  of  painful 
fissures  and  excoriations.  In  painful  diseases  of 
the  breast,  tender  areas  occur  over  the  fourth  and 
fifth  spinal  segments  (Fig.  56,  p.  333)  (Head). 

The  breast  is  developed  by  a  solid  invagination 
of  epiblast  at  the  point  afterwards  marked  by 
the  nipple.  About  the  sixth  month  of  foetal  life 
the  primitive  mammary  bud  branches  out  in  all 
directions  within  the  subcutaneous  tissue.  Thus 
it  comes  about  that  the  subcutaneous  fascia  is  con- 
densed around  the  gland,  forming  its  capsule.  The 
retromammary  part  of  the  capsule  is  connected  at 
the  interlobular  spaces  with  the  superficial  layer, 
which  in  turn  is  fixed  to  the  skin  by  subcutaneous 
bands,  or  skin  ligaments. 

It  is  through  lymph  channels  that  cancer 
spreads,  and  those  of  the  breast,  which  is  one  of 
the  commonest  sites  of  cancer,  are  of  especial  im- 
portance if  complete  eradication  of  the  disease  is 
to  be  obtained.  The  lymph  vessels  are  arranged  in 
the  following  sets  :  (1)  Perilobular,  round  the 
acini  and  lobules ;  (2)  periductal,  round  the  lac- 
tiferous ducts ;  (3)  interlobar,  situated  in  the 
interlobar   septa   and   joining    (4)   the   retromam- 


204  SUPGICAL   APPLIED    ANATOMY     [Part  II 

mary  network  with  (5)  the  superficial  mammary 
in  the  anterior  part  of  the  capsule.     If  the  inter- 
lobar septa  are  invaded  by  cancer  they  contract, 
and    through   their    cutaneous    attachments   cause 
depressions  in  the  skin ;  if  the  process  invades  the 
periductal   vessels,   the   nipple   is   retracted.     The 
mammary  lymphatic  system  is  connected  with  the 
subcutaneous  network  of  vessels,  to  which  cancer 
may  spread,  producing  that  variety  of  the  disease 
known  as  cancer  en  cuirasse.     Through  communi- 
cations with  the  lymph  channels  of  the  pectoral 
fascia  and  muscle,  cancer  of  the  breast  may  spread 
to    these    structures.      The    gland    then    becomes 
firmly  fixed  to  the  deeply  seated  structures.     The 
majority  of  the  lymph  vessels  pass  from  the  breast 
to  the   pectoral  glands,   six  to   eight  in   number, 
situated  along  the  anterior  border  of  the  axilla, 
and  to  the  central  axillary  set,  twelve  to  fifteen 
in  number,  situated  beneath  the  axillary  tuft  of 
hair  and  on  the  inner  side  of  the  axillary  vein. 
From  these  two  sets  the  lymph  vessels  pass  to  the 
deep   axillary  glands   lying   along  the   front   and 
inner  side  of  the  axillary  vessels.     The  deep  axil- 
lary glands  become  continuous  with  the  lower  deep 
cervical  glands.     It  is  mainly  along  this  path  that 
cancer  tends  to  spread,  but  vessels  leave  the  inner 
segment  of  the  breast  and   pass  to   the   anterior 
intercostal    glands    situated    in    the    upper    four 
intercostal  spaces  and  lying  on  each  side  of  the 
internal   mammary   vessels,    while    occasionally    a 
few   vessels   pass   to   the   cephalic   gland    situated 
in  the  hiatus  between  the   deltoid  and  pectoralis 
major    muscles.     Handley    found    a    marked    ten- 
dency for  breast  cancer  to  spread  downwards  in 
the  lymphatics,  passing  to  the  epigastric  triangle, 
where  they  perforate  the  belly  wall  to  join  lym- 
phatics both  above  and  below  the  diaphragm ;  it 
is  probably  owing  to  this  communication  that  the 
liver  is  so  often  the  seat  of  secondary  deposit  in 
cases  of  cancer  of  the  breast.     When  the  normal 
channels  become  clogged  with  cancerous  emboli  the 
lymph  passes  by  circuitous  paths.     The  subscapu- 


Chap.  X]  THE    THORAX  205 

lar  glands,  surrounding  the  subscapular  vessels  on 
the  posterior  wall  of  the  axilla,  may  become  in- 
filtrated; through  the  lymphatics  of  the  arm, 
which  end  in  the  central  axillary  glands,  the 
structures  round  the  shoulder  may  become  the 
seats  of  secondary  deposit,  and  through  the  com- 
munication between  the  lymph  system  of  one 
breast  with  that  of  the  other,  across  the  sternum, 
a  secondary  deposit  may  even  occur  in  the  oppo- 
site breast  (Stiles). 

The  breast  is  thinnest  along  a  line  drawn 
from  the  sterno-clavicular  joint  to  the  nipple. 
Abscesses  situated  beneath  the  breast  not  unfre- 
quently  make  their  way  through  the  gland  at  some 
point  along  this  line.  Abscesses  of  the  breast 
should  be  opened  by  incisions  radiating  from  the 
nipple,  to  avoid  wounding  the  lactiferous  ducts. 

The  intercosto-humeral  nerve  pierces  the  cen- 
tral set  of  axillary  glands.  It  becomes  compressed 
when  these  glands  are  invaded  by  cancer,  and 
pain  is  referred  to  the  termination  of  the  nerve 
over  the  posterior  aspect  of  the  arm  above  the 
elbow.  Various  parts  of  the  brachial  plexus  may 
also  become  involved  or  the  axillary  vein  or  lym- 
phatics occluded,  the  arm  being  swollen  and 
cedematous   in   consequence. 

The  following  groups  of  arteries  supply  the 
gland  and  are  cut  in  excision  of  the  organ  :  (l) 
the  long  thoracic,  alar  thoracic,  thoracic  branches 
of  the  acromio-thoracic  axis ;  (2)  anterior  perfor- 
ating branches  from  the  internal  mammary  at  the 
second,  third,  and  fourth  intercostal  spaces ;  (3) 
lateral  branches  from  the  second,  third,  and 
fourth   intercostal    arteries. 

Supernumerary  nipples  and  breasts  may  occur. 
They  are  commonly  found  in  a  line  between  the 
axilla  and  the  groin.  In  the  embryonic  stage  of 
all  mammals  an  epiblastic  mammary  ridge  is 
found  in  this  position.  In  man  it  disappears 
except  at  one  point,  but  occasionally  some  isolated 
part  may  persist  and  proceed  to  form  a  breast. 
Embryology    fails   to   explain    the   occurrence   of 


206 


SURGICAL    APPLIED    ANATOMY     [Part  II 


breasts  on  the  buttock  or  back,   where  they  are 
occasionally  found. 

2.  The  thoracic   viscera. 

The  lung*. — The  apex  of  the  lung  rises  in  the 
neck  from  1  to  2  inches  above  the  inner  half  of 
the  clavicle.  Its  highest  point  in  the  majority 
of  adults  lies  1|  inch  above  the  sternal  end  of 
the  clavicle,   in  the  interval  between  the  sternal 

Pulmonary  Apex 

iX  LAV  I  CLE: 

Pleural  Lime 
.Stereo-  AIanub. Point 


/ilPPLE 

Uncovered  Area 
5TER/10-  ErtSIf  ORN  Poifll 


Pulmonary  Line 

Pleural  Line 
2" 


Apex  Point 
Pulmonary  Line 

Pleural  Line 
2" 


Fig.  37. — Diagram  showing  the  surface  markings  for  the  lungs  and  pleura. 

and  clavicular  heads  of  the  sterno-mastoid  muscle 
(Fig.  37).  The  anterior  edges  of  the  two  lungs 
pass  behind  the  sternoclavicular  articulations, 
and  meet  in  the  middle  line  at  the  junction  of  the 
manubrium  with  the  gladiolus.  The  edge  of  the 
right  lung  then  continues  vertically  downwards 
behind  the  middle  line  of  the  sternum  to  the  sixth 
chondro-sternal  articulation,  where  it  slopes  off 
along  the  line  of  the  sixth  cartilage.  The  edge  of 
the  left  lung  keeps  close  to  that  of  the  right  as  far 


Chap.  X]  THE   THORACIC   VISCERA  207 

as  the  fourth  chondro-sternal  articulation,  where 
it  turns  off  to  the  left,  following  a  line  drawn 
from  the  fourth  cartilage  to  near  the  apex  of  the 
heart  (Fig.  37).  Occasionally  it  does  not  diverge, 
but  completely  covers  the  pericardium  up  to  the 
edge  of  the  sternum.  In  the  child,  owing  to  the 
thymus,  the  lungs  are  more  separated  in  front. 
The  right  reaches  the  middle  line,  but  the  left  only 
reaches  the  left  edge  of  the  sternum  (Symington). 
The  easiest  and  also  the  most  accurate  method  of 
indicating  the  lower  border  of  the  lung  is  the  fol- 
lowing (Fig.  37)  :  A  line  is  drawn  along  the  sixth 
costal  cartilaere  from  its  sternal  end  to  its  heel; 
from  the  heel  the  line  is  carried  horizontally 
round  the  body;  it  will  be  found  to  cross  the 
median  line  behind,  at,  or  near  the  eleventh  dorsal 
spine  (the  anticlinal  spine).  The  corresponding 
border  of  the  pleura  is  not  parallel  to  the  lower 
border  of  the  lung ;  it  is  indicated  by  a  line  drawn 
along  the  seventh  costal  cartilage  from  its  sternal 
end  to  its  heel ;  from  there  the  line  is  continued 
to  a  point  2  inches  above  the  lowest  part  of  the 
subcostal  margin  and  then  prolonged  horizontally 
to  the  median  line  behind  where  it  crosses  at  or 
near  the  twelfth  dorsal  spine.  Between  the  pul- 
monary line  above  and  the  pleural  line  below,  the 
diaphragm  is  in  contact  with  the  chest  wall,  separ- 
ated only  by  the  costo-phrenic  reflection  of  the 
pleura.  On  the  left  side  these  lines  commence  at 
a  variable  distance  from  the  sternum — 1  inch 
should  be  allowed  for  the  pleura;  2-§-  inches  for  the 
lung  (Fig.  37).  The  pleura  is  in  relation  with 
the  twelfth  rib,  but  occasionally  it  descends  |  an 
inch  or  more  below  this  point,  and  may  be 
wounded  in  operations  on  the  kidney  (Fig.  65, 
p.  402).  It  extends  lower  down  in  the  child  than 
in  the  adult.  The  left  lung  descends  to  a  slightly 
lower  level  than  the  right. 

In  penetrating  wounds  involving  the  pleura^ 
air  may  enter  the  pleural  cavity,  producing 
pneumothorax,  and  this  air  may  be  subsequently 
pressed  by   the   respiratory   movements   into   the 


208  SURGICAL    APPLIED    ANATOMY     [Part  II 

subcutaneous  tissues  through  the  wound  in  the 
parietal  pleura,  and  lead  to  surgical  emphysema. 
The  cohesion  between  the  smooth  pulmonary  and 
parietal  layers  of  pleura  is  such  that  occasionally 
collapse  does  not  follow,  but  the  intimate  connec- 
tion between  them  makes  it  difficult  for  the  pul- 
monary to  escape  when  the  parietal  layer  is 
wounded.  In  wounds  of  the  lung  without  exter- 
nal wound,  as  when  that  organ  is  torn  by  a 
fractured  rib,  the  air  escapes  from  the  lung  into 
the  pleura,  and  may  thence  pass  into  the  subcu- 
taneous tissues  through  the  pleural  wound,  thus 
producing  both  pneumothorax  and  emphysema. 

It  is  well  to  note  that  emphysema  may  occur 
about  certain  non-penetrating  wounds  of  the 
thorax  when  they  are  of  a  valvular  nature.  In 
such  cases  the  air  is  drawn  into  the  subcutaneous 
tissues  during  one  respiratory  movement,  and  is 
forced  by  another  into  the  cellular  tissue,  the  valv- 
ular nature  of  the  wound  preventing  its  escape 
externally.  When  the  pleural  "  cavity  ;'  is  opened, 
the  lungs,  owing  to  the  amount  of  elastic  tissue 
they  contain,  undergo  some  degree  of  collapse,  but 
there  is  much  misconception  regarding  the  extent 
to  which  this  takes  place.  Half  the  air  in  the 
lung,  in  some  cases  even  two-thirds,  is  residual 
and  cannot  be  expelled  by  the  passive  collapse  of 
the  lung;  when  the  diaphragm  is  pushed  up  and 
the  ribs  are  pulled  down  by  the  expiratory  efforts 
of  the  muscles  of  the  belly  wall  the  thoracic  space 
may  be  so  reduced  in  size  that  the  lung  still  more 
than  fills  it ;  if  the  glottis  be  closed  a  hernia  of  the 
lung  will  occur  through  the  wound  in  the  chest 
wall.  If,  however,  there  is  a  valvular  orifice  into 
the  pleural  cavity,  so  that  air  can  be  sucked 
in  but  not  expelled  from  it,  every  respiratory 
effort  increases  the  amount  of  air  in  the  pleural 
snace ;  then  compression  of  the  lung  and  suffoca- 
tion quickly  ensue.  MacEwen  is  of  opinion  that 
collapse  of  the  lung  is  prevented  by  the  capillary 
attraction  which  exists  between  the  visceral  and 
parietal  layers  of  the  pleura. 


Chap.  X] 


THE   THORACIC   YISCERA 


209 


In  wounds  of  the  lung  the  blood  may  escape 
in  three  directions  :  into  the  tissue  of  the  organ 
(pulmonary  apoplexy),  into  the  bronchi  (causing 
haemoptysis),  and  into  the  pleura  (causing  hsemo- 
thorax).  In  some  instances  the  lung  has  been  rup- 
tured without  wound  and  without  fracture  to  the 
ribs.     These  cases  are   difficult  to   interpret,    and 


Right  Int.  Juc  lilac  Vewn 

Right  Subclavian  Ve 
Right    Innoni-vein 

5tep.no     ManuB.Poin 

SuPERKDR  VENACAV 

Pericardium 
RiCmt  Auricle 

JRiCulC  -VENTRICULAR 

q«.oovE 
Dome: 
,teknoE:nsiforn  Line- 
mferioR  Caval  Point 
erno*  cnsiforn  poim 
nferiOR  Vena  Cava 


Left  InnominateVein 

Arch  op  Aorta 
Pulmonary  Artery 

Left  Ventricle 

/ilPPLE- 
RlQHT  VENTRICLE; 


Left  Dome 
Apex  Point 


Fig.  3S.— The  relationship  of  the  pericardium  and  heart  to  the  sternum 

and  ribs. 


probably  the  best  explanation  suggested  is  that 
put  forward  by  M.  Gosselin.  This  surgeon  be- 
lieves that  at  the  time  of  the  injury  the  lungs  are 
suddenly  filled  and  distended  with  air  by  a  full 
inspiration,  and  that  the  air,  prevented  from 
escaping  by  occlusion  of  the  larynx,  thus  becomes1 
pent  up  in  the  pulmonary  tissue,  and  the  lung  not 
being  able  to  recede  from  the  superincumbent  pres- 
sure, its  structure  necessarily  gives  way. 

Owing  to  the  fineness  of  its  capillaries,  and  to 
o 


210  SURGICAL    APPLIED    ANATOMY     [Part  II 

the  fact  that  all  venous  blood  returned  to  the  heart 
must  pass  through  the  lungs  before  it  can  reach 
other  parts  of  the  body,  it  follows  that  pysemic 
and  other  secondary  deposits  are  more  commonly 
met  with  in  the  lung  than  in  any  other  of  the  viscera. 

Lung  cavities  resulting  from  tuberculosis,  gan- 
grene, or  bronchiectasis  have  been  successfully  in- 
cised and  drained,  and  the  same  measure  has  been 
applied  to  hydatid  cysts  of  the  lung.  Deep  in- 
cisions in  the  lung  are  followed  by  less  haemor- 
rhage than  might  be  expected  from  such  a  vascular 
organ. 

The  trachea  divides  opposite  the  junction  of 
the  manubrium  and  gladiolus  in  front,  and  the 
fourth   dorsal  vertebra  behind. 

Certain  foreign  substances  that  have  been 
drawn  into  the  air  passages  have  shown  a  remark- 
able facility  for  escaping  through  the  parietes. 
Thus  Mr.  Godlee  records  the  case  of  a  child,  from 
an  abscess  in  whose  back  there  escaped  a  head  of 
rye-grass  that  had  found  its  way  into  the  air  pas- 
sages forty-three  days  previously. 

The  root  of  the  lung  and  bronchi  can  be  ex- 
posed by  opening  the   dorsal  wall  of  the  thorax 
behind  the  vertebral  border  of  the  scapula.     Rus- 
sell and  Fox  record  the  case  of  a  boy  in  whom  a 
pin,  3  inches  long,  had  slipped  head  downwards 
within  the  trachea,  and  ultimately  lodged  in  the 
lower  division  of  the  left  bronchus.     They  resected 
part  of  the  eighth  rib  from  the  back,  pushed  the 
lung  forwards  to  expose  the  bronchus  at  the  root, 
and  removed  the  pin.     The  root  of  the  lung  re- 
quires to  be  steadied;  through  the  pericardium  it 
is  intimately  bound  to  the  diaphragm  and  follows 
the  movements  of  that  muscle.     In  the  case  men- 
tioned above,  the  boy  was  able  to  leave  the  hospital 
I  twelve    days   after   the   operation. 
•^     The  heart  and  pericardium.—  The  position 
and  extent  of  the  pericardium  may  be  indicated 
thus  on  the  surface  of  the  thorax  (Fig.  38)  :  Three 
points  are  taken:    (1)  the  apical,  over  the  apex 
beat,  in  the  fifth  left  intercostal  space,  3^  inches 


Ohap.  X]  THE    THOKACIC   VISCERA  211 

from  the  sternum ;  (2)  the  sterno-manubrial,  mid- 
way between  the  insertions  of  the  second  costa] 
cartilages;  (3)  the  inferior  cava!,  1  inch  to  the 
right  of  the  sterno-ensiform  point  and  directly 
superficial  to  the  termination  of  the  inferior  vena 
cava.  When  these  three  points  are  united  by 
curved  lines,  as  in  Fig.  38,  the  area  over  the  peri- 
cardium and  its  contents  is  marked  out.  The 
lower  line  crosses  \  an  inch  or  more  below  the 
sterno-ensiform  point ;  if  a  trochar  be  thrust  back- 
wards in  the  angle  between  the  ensiform  process 
and  seventh  left  costal  cartilage,  it  enters  the 
pericardium  just  above  the  diaphragm.  Through 
this  angle  the  pericardium  may  be  drained ;  by 
resecting  part  of  the  sixth  and  seventh  cartilages 
its  cavity  may  be  explored.  The  right  border  of 
the  pericardium  is  deeply  placed  and  covered  by 
the  right  lung  (Fig.37);  in  health  it  should  not 
project  more  than  1  inch  beyond  the  right  sternal 
border. 

Besides  the  auricles  and  ventricles  the  follow- 
ing parts  are  contained  in  the  pericardium  :  The 
terminations  of  the  inferior  and  superior  venae 
cava?;  the  ascending  aorta  and  pulmonary  artery. 
The  position  of  these  parts,  and  of  the  arch  of  the 
aorta  and  its  branches,  is  shown  in  Fig.  38.  It 
will  be  observed  that  more  than  two-thirds  of  the 
anterior  surface  of  the  heart  is  made  up  of  right 
ventricle  and  auricle ;  consequently  it  is  these  ^ 
parts  which  are  usually  perforated  in  stabs  of  the// 
heart.  / 

The  heart  may  be  exposed  for  operative  treat- 
ment by  removal  of  the  terminal  inch  or  more  of 
the  fourth  and  fifth  left  costal  cartilages.  The 
heart  may  be  freely  handled  and  sutured;  the  sur- 
geon's task  is  rendered  difficult  by  its  rapid 
motions  and  the  respiratory  movements  of  the 
pericardium  and  diaphragm.  When  the  heart  is 
wounded,  blood  escapes  into  the  pericardium,  lead- 
ing to  compression  of  the  auricles  and  the  arrest  of 
the  inflow  of  blood.  Hydrops  of  the  pericardium 
may    cause    death    in    a    similar    manner.     Other 


212  SURGICAL    APPLIED    ANATOMY      [Part  II. 

things  being  equal,  a  wound  of  the  ventricle  is 
less  rapidly  fatal  than  is  a  wound  of  the  auricle, 
owing  to  the  thickness  of  the  ventricular  wall, 
and  to  its  capacity  for  contracting  and  prevent- 
ing the  escape  of  blood.  Death  in  cases  of  wound 
of  the  heart  would  appear  in  a  great  number  of 
cases  to  be  due  to  an  impression  upon  the  nervous 
centres  rather  than  to  actual  haemorrhage.  Many 
instances  have  been  recorded  to  show  that  the 
heart  may  be  very  tolerant  of  foreign  bodies  in 
its  substance.  Thus  a  man  lived  for  twenty  days 
with  a  skewer  traversing  the  heart  from  side  to 
side  (Ferrus).  In  another  case  a  lunatic  pushed 
an  iron  rod,  over  6  inches  in  length,  into  his 
chest,  until  it  disappeared  from  view,  although  it 
could  be  felt  beneath  the  skin  receiving  pulsation 
from  the  heart.  He  died  a  year  following,  and 
the  metal  was  found  to  have  pierced  not  only  the 
lungs  but  also  the  ventricular  cavities  (Tillaux). 
Wounds  of  the  heart  have  been  sutured,  the  in- 
sertion of  the  stitches  causing  only  momentary 
disturbance  of  its  action.  Recently  Travers 
sutured  a  wound  of  the  right  ventricle  into  which 
he  was  able  to  place  three  fingers  to  prevent 
haemorrhage.  A  propos  of  chest  wounds,  Velpeau 
cites  the  case  of  a  man  in  whose  thorax  was  found 
a  part  of  a  foil  that  entirely  transfixed  the  chest 
from  ribs  to  spine,  and  that  had  been  introduced 
fifteen  years  before  death.  In  the  museum  of  the 
Royal  College  of  Surgeons  is  the  shaft  of  a  cart 
that  had  been  forced  through  the  ribs  on  the  left 
side,  had  passed  entirely  through  the  chest,  and 
had  come  out  through  the  ribs  on  the  right  side. 
The  patient  had  lived  ten  years. 

Paracentesis  of  tlie  pericardium.— As  al- 
ready mentioned,  the  pericardium  may  be  tapped 
or  drained  through  the  left  costo-ensiform  angle 
(Fig.  38).  The  extent  to  which  it  is  covered  by 
the  left  pleura  and  lung  is  extremely  variable, 
but  in  the  majority  of  cases  it  may  be  tapped  in 
the  left  fourth  and  fifth  spaces,  up  to  1  inch  from 
the   sternum,    without   injuring  the   pleura.     The 


Chap.  X]  THE   THORACIC   VISCERA  2l3 

internal  mammary  artery  descends  in  these  spaces 
.7  an  inch  from  the  sternum,  and  divides,  behind 
the  seventh  cartilage,  into  its  superior  epigastric 
and  musculo-phrenic  branches. 

The  iiiediastiua.  —  Abscess  in  the  anterior 
mediastinum  may  have  developed  in  situ,  or  may 
have  spread  down  from  the  neck.  In  like  manner 
posterior  mediastinal  abscesses  may  arise  from 
diseases  of  the  adjacent  spine,  or  lymphatic 
glands,  or  may  be  due  to  the  spreading  down- 
wards of  a  retropharyngeal  or  retro-oesophageal 
collection  of  matter. 

The  azygos  veins,  commencing  as  they  do  below 
in  the  lumbar  veins,  and  having  more  or  less  direct 
communications  with  the  common  iliac,  renal, 
and  other  tributaries  to  the  vena  cava,  are  able 
to  a  great  extent  to  carry  on  the  venous  circula- 
tion in  cases  of  obstruction  of  the  terminal  part 
of  the  superior  vena  cava.  In  this  they  are  as- 
sisted by  the  vense  comites  of  the  internal  mam- 
mary artery  and  epigastric  veins;  the  intraverte- 
bral  veins  also  become  greatly  enlarged,  and  serve 
as  anastomotic  channels  between  the  superior  and 
inferior  caval  systems. 

These  veins  are  apt  to  be  pressed  upon  by 
tumours  (such  as  enlarged  gland  masses)  de- 
veloped in  the  posterior  mediastinum,  and  to  pro- 
duce in  consequence  some  oedema  of  the  chest 
walls  by  engorgement  of  those  intercostal  veins 
that  they  receive.  Tumours  growing  in  the  pos- 
terior mediastinum  may  cause  trouble  by  press- 
ing upon  the  trachea  or  gullet,  or  by  disturbing 
the  vagus  nerve  or  the  cord  of  the  sympathetic. 
The  numerous  lymphatic  glands  which  surround 
the  trachea,  bronchi,  and  oesophagus  are  often  the 
seat  of  tuberculosis.  They  become  adherent  to 
these  organs  and  may  ulcerate  into  them. 

Krabbel  reports  a  case  of  fracture  of  the  ninth 
dorsal  vertebra  associated  with  rupture  of  the 
thoracic  duct.  The  patient  died  in  a  few  days, 
and  the  right  pleura  was  found  to  contain  more 
than  a  gallon  of  pure  chyle. 


Part  III.-THE  UPPER  EXTREMITY 

CHAPTER  XI 

THE  REGION  OF  THE  SHOULDER 

A  study  of  the  region  of  the  shoulder  comprises 
the  clavicle,  the  scapula,  the  upper  end  of  the 
humerus,  and  the  soft  parts  that  surround  them, 
together  with  the  shoulder  joint  and  axilla. 

Surface  anatomy.— The  clavicle,  acromion 
process,  and  scapular  spine  are  all  subcutaneous, 
and  can  be  readily  felt.  In  the  upright  position, 
when  the  arm  hangs  by  the  side,  the  clavicle  is, 
as  a  rule,  not  quite  horizontal.  In  well-developed 
subjects  it  inclines  a  little  upwards  at  its  outer 
end.*  In  the  recumbent  posture,  the  weight  of  the 
limb  being  taken  off,  the  outer  end  rises  still 
higher  above  the  sternal  extremity.  The  degree 
of  the  elevation  can  be  best  estimated  by  a  study 
of  frozen  sections.  Thus,  in  making  horizontal 
sections  of  the  body,  layer  by  layer,  from  above 
downwards,  Braune  found  that  by  the  time  the 
sterno-clavicular  articulation  was  reached,  the 
head  of  the  humerus  would  be  cut  across  in  the 
lateral  part  of  the  section  (Fig.  39). 

The  deltoid  tubercle  of  the  clavicle  may,  if 
large,  be  felt  through  the  skin,  and  be  mistaken 
for  an  exostosis.  The  acromio-clavicular  joint  lies 
in  the  plane  of  a  vertical  line  passing  up  the 
middle  of  the  front  of  the  arm.  A  prominence  is 
sometimes   felt  about  this  joint  in   place  of  the 

*    Tn  some  women,  in  the  feeble,  and  in  some  narrow-shouldered  men 
the  clavicle  may  be  horizontal,  or  its  outer  end  may  incline  downwards. 

214 


Chap.  XI]     EEGION    OF    THE    SHOULDER  215 

level  surface  that  it  should  present.  This  is  due 
to  an  enlargement  of  the  end  of  the  clavicle,  or 
to  a  thickening  of  the  fibro-cartilage  sometimes 
found  in  the  joint.  In  many  cases  it  has  ap- 
peared to  me  to  be  due  to  a  trifling  luxation  up- 
wards of  the  clavicle  depending  upon  some  stretch- 
ing of  the  ligaments.  It  is  certain  that  the  dry- 
bone  seldom  shows  such  an  enlargement  as  to 
account  for  this  very  common  prominence  at  the 
acromial  articulation.  The  sternal  end  of  the 
clavicle  is  also,  in  muscular  subjects,  often  large 
and  unduly  prominent,  and  sufficiently  conspicu- 
ous to  suggest  a  lesion  of  the  bone  or  joint  when 
none  exists. 

The  roundness  and  prominence  of  the  point  of 
the  shoulder  depend  upon  the  development  of  the 
deltoid  and  the  position  of  the  upper  end  of  the 
humerus.  The  deltoid  hangs  like  a  curtain  from 
the  shoulder  girdle,  and  is  bulged  out,  as  it  were, 
by  the  bone  that  it  covers.  If  the  head  of  the 
humerus,  therefore,  be  diminished  in  bulk,  as  in 
some  impacted  fractures  about  the  anatomical 
neck,  or  be  removed  from  the  glenoid  cavity,  as  in 
dislocations,  the  deltoid  becomes  more  or  less  flat- 
tened, and  the  acromion  proportionately  promi- 
nent. The  part  of  the  humerus  felt  beneath  the 
deltoid  is  not  the  head,  but  the  tuberosities,  the 
greater_  tuberosity  externally,  the  lesser  in  front. 
A  considerable  portion  of  the  head  of  the  bone 
can  be  felt  by  the  fingers  placed  high  up  in  the 
axilla,  the  arm  being  forcibly  abducted  so  as  to 
bring  the  head  in  contact  with  the  lower  part  of 
the  capsule.  The  head  of  the  humerus  faces  very 
much  in  the  direction  of  the  internal  condyle.  As 
this  relation,  of  course,  holds  good  in  every  posi- 
tion of  the  bone,  it  is  of  value  in  examining 
injuries^  about  the  shoulder,  and  in  reducing 
dislocations  by  manipulation,  the  condyle  being 
used  as  an  index  to  the  position  of  the  upper  end 
of  the  bone. 

In  thin  subjects  the  outline  and  borders  of 
the  scapula  can  be  more  or  less  distinctly  made 


216  SURGICAL    APPLIED    ANATOMY    [Part  III 

out,  but  in  fat  and  muscular  subjects  all  parts 
of  the  bone,  except  the  spine  and  acromion,  are 
difficult  of  access  in  the  ordinary  positions  of  the 
limb.  To  bring  out  the  superior  angle  and  verte- 
bral border  of  the  bone,  the  hand  of  the  subject 
should  be  carried  as  far  as  possible  over  the  oppo- 
site shoulder.  To  bring  out  the  inferior  angle 
and  axillary  border,  the  forearm  should  be  placed 
behind  the  back.  The  angle  formed  at  the  point 
of  junction  of  the  spine  of  the  scapula  and  the 
acromion  is  the  best  point  from  which  to  take 
measurement  of  the  arm,  the  tape  being  carried 
down  to  the  external  condyle  of  the  humerus.  The 
upper  border  of  the  scapula  lies  on  the  second 
rib,    its    lower    angle    on    the    seventh. 

When  the  arm  hangs  from  the  side  with  the 
palm  of  the  hand  directed  forwards,  the  acromion, 
external  condyle,  and  styloid  process  of  the  radius 
all  lie  in  the  same  line.  The  groove  between  the 
pectoralis  major  and  deltoid  muscles  is  usually 
to  be  made  out.  In  it  run  the  cephalic  vein  and 
a  large  branch  of  the  acromio-thoracic  artery. 
Near  the  groove,  and  a  little  below  the  clavicle, 
the  coracoid  process  may  be  felt.  The  process,  how- 
ever, does  not  actually  present  in  the  interval 
between  the  two  muscles,  but  is  covered  by  the 
innermost  fibres  of  the  deltoid.  The  position  of 
the  coraco-acromial  ligament  may  be  defined,  and 
a  knife  thrust  through  the  middle  of  it  should 
strike  the  biceps  tendon  and  open  the  shoulder 
joint. 

When  the  arm  hangs  at  the  side  with  the  palm 
forwards,  the  bicipital  groove  may  be  defined 
directly  below  the  acromioclavicular  joint. 

Just  below  the  clavicle  is  a  depression,  the  sub- 
clavicular fossa,  which  varies  considerably  in 
depth  in  different  subjects.  It  is  obliterated  in 
subcoracoid  dislocations  of  the  humerus,  in  frac- 
tures of  the  clavicle  with  displacement,  by  many 
axillary  growths,  and  by  some  inflammations  of 
the  upper  part  of  the  thoracic  wall.  In  sub- 
clavicular or  infracoracoid  dislocation,  the  fossa 


Chap.  XI]     REGION    OF    THE    SHOULDER  217 

is  replaced  by  an  eminence.  In  this  region,  at  a 
spot  to  the  inner  side  of  the  coracoid  process,  and 
corresponding  nearly  to  the  middle  of  the  clavicle;, 
the  pulsations  of  the  axillary  artery  can  be  felt 
on  deep  pressure,  and  the  vessel  be  compressed 
against  the  second  rib.  Just  below  the  clavicle  the 
interspace  between  the  sternal  and  clavicular  por- 
tions of  the  pectoralis  major  can  often  be  made 
out. 

The  anterior  and  posterior  borders  of  the  axilla 
are  very  distinct.  The  anterior  border,  formed 
by  the  lower  edge  of  the  pectoralis  major,  follows 
the  line  of  the  fifth  rib.  The  depression  of  the 
armpit  varies,  other  things  being  equal,  with  the 
position  of  the  upper  limb.  It  is  most  deep  when 
the  arm  is  raised  from  the  side  at  an  angle  of 
about  45°,  and  when  the  muscles  forming  the  bor- 
ders of  the  space  are  in  a  state  of  contraction. 
As  the  arm  is  raised  above  the  horizontal  line  the 
depression  becomes  shallower,  the  head  of  the  bone 
projects  into  the  space  and  more  or  less  obliterates 
it,  while  the  width  of  the  fossa  is  encroached  upon 
by  the  approximation  of  the  anterior  and  pos- 
terior folds.  The  coraco-brachialis  muscle  itself 
forms  a  distinct  projection  along  the  humeral 
side  of  the  axilla  when  the  arm  is  raised  to  a 
right  angle  with  the  body.  If  the  arm  be  brought 
nearly  close  to  the  side,  the  surgeon's  hand  can 
be  thrust  well  up  into  the  axilla,  and  the  thoracic 
wall  explored  as  high  up  as  the  third  rib. 

The  axillary  glands  cannot  be  felt  when  they 
are  in  a  normal  condition.  The  central  set  lies 
beneath  the  axillary  tuft  of  hair. 

The  direction  of  the  axillary  artery,  when  the 
arm  is  raised  from  the  side,  is  represented  by  a 
line  drawn  from  the  middle  of  the  clavicle  to  the 
humerus  at  the  inner  side  of  the  coraco-brachialis. 
A  line  drawn  from  the  third  rib  near  its  cartilage 
to  the  tip  of  the  coracoid  process  indicates  the 
upper  border  of  the  pectoralis  minor,  and  the  spot 
where  this  line  crosses  the  line  of  the  axillary 
artery    points   out   the    position   of   the   acromio- 


218 


SURGICAL   APPLIED    ANATOMY    [Part  III 


thoracic  artery.  A  line  drawn  from  the  fifth  rib 
near  its  cartilage  to  the  tip  of  the  coracoid  process 
indicates  the  lower  border  of  the  pectoralis  minor, 
and  the  position  of  the  long  thoracic  artery  which 
runs  along  that  border.  The  line  of  the  sub- 
scapular artery  corresponds  to  the  lower  border 


2     1   \? 


,a       T 


9 


r  /•''£■'    /  /  •  ■'  \    \ 


Fig.  39. 


f     8 

-Horizontal  section  of  the  body  just  below  the  upper  border 
of  the  manubrium.     (Braune.) 

a,  Manubrium  ;  b,  head  of  humerus  ;  c,  clavicle  ;  d,  first  rib ;  e,  second  rib  ;  /;  third 
dorsal  vertebra;  g,  spine  of  second  dorsal;  ft,  pectoralis  major;  i,  deltoid; 
j,  infraspinatus  ;  fc,  subscapularis  ;  I,  coraco-brachialis  and  biceps  :  m,  pectoralis 
minor ;  n,  serratus  magnus ;  o,  intercostals ;  p,  semispinalis  and  undtifidus 
spina?;  q,  biventer  cervicis  and  complexus ;  r,  longissimus  dorsi;  s,  splenius 
colli  ;  t,  rhomboideus  ;  u,  trapezius  ;  v}  sterno-thyroid  ;  w,  sterno-hyoid  ; 
T,  thymus  ;  l,  lung ;  1,  left  innominate  vein  ;  2,  left  carotid  artery  ;  3,  left  sub- 
clavian artery  ;  4,  vertebral  artery  ;  5,  left  subclavian  vein ;  G,  cephalic  vein  ; 
7,  phrenic  nerve  ;  8,  vagus  ;  9,  transverse  scapular  artery. 

of  the  subscapularis  muscle  along  which  it  runs, 
but  the  position  of  this  border  can  only  be  ap- 
proximately indicated  on  the  living  or  undissected 
sub  j  ect. 

The  circumflex  nerve  and  posterior  circumflex 
artery  cross  the  humerus  in  a  horizontal  line  that 
is  about  a  finger's  breadth  above  the  centre  of  the 
vertical   axis  of  the   deltoid   muscle.     This   point 


Chap.  XI]    EEGION    OF    THE   SHOULDEE  219 

is  of  importance  in  cases  of  supposed  contusion 
of  the  nerve.  These  various  indications  of  the 
positions  of  the  main  branches  of  the  axillary 
artery  are  made  while  the  arm  hangs  in  its 
natural  position  at  the  side. 

The  clavicle. — The  skin  over  the  clavicle  is 
loosely  attached,  and  is  easily  displaced  about  the 
bone.  This  circumstance  may  serve  to  explain 
why  the  skin  so  often  escapes  actual  wound  in 
contusions  of  the  clavicular  region,  and  in  part 
explains  the  infrequency  of  penetration  of  the 
integument  in  fractures  of  the  clavicle.  The  posi- 
tion of  the  supraclavicular  nerves  in  front  of  the 
bone  renders  them  very  liable  to  contusion,  and 
accounts  for  the  unusual  amount  of  pain  that  is 
said  to  sometimes  follow  blows  over  the  collar 
bone.  Tillaux  believes  that  the  severe  pain  that  in 
rare  cases  persists  after  fracture  of  the  clavicle  is 
due  to  the  implication  of  these  nerves  in  the  callus 
formed.  The  three  nerves  that  cross  the  clavicle 
are  branches  of  the  third  and  fourth  cervical 
nerves,  and  it  is  well  to  note  that  pain  over  the 
collar  bone  is  sometimes  a  marked  feature  in 
disease  of  the  upper  cervical  spine.  This  symp- 
tom is  then  due  to  irritation  of  these  nerves  at  their 
points  of  exit  from  the  spinal  canal.  A  communica- 
tion between  the  external  jugular  and  cephalic 
veins  is  occasionally  seen  to  cross  the  clavicle. 

Beneath  the  clavicle  the  great  vessels  and  the 
great  nerve-cords  lie  upon  the  first  rib.  The  vein 
is  the  most  internal,  and  occupies  the  acute  angle 
between  the  collar-bone  and  the  first  rib.  It  will 
be  seen  that  growths  from  the  bone  may  readily 
press  upon  these  important  structures,  and  that 
the  vein,  from  its  position,  as  well  as  from  the 
slighter  resistance  that  it  offers,  is  likely  to  be 
the  first  to  be  compressed.  These  structures  have 
also  been  wounded  by  fragments  of  bone  in  frac- 
ture of  the  clavicle.  Fortunately,  between  the 
clavicle  and  these  large  nerves  and  vessels  the 
subclavius  muscle  is  interposed.  This  muscle  is 
closely  attached  to  the  under  surface  of  the  bone, 


220  SURGICAL   APPLIED    ANATOMY    [Part  III 

is  enveloped  in  a  dense  fascia,  and  forms  one  of 
the  chief  protections  to  the  vessels  in  case  of  frac- 
ture. This  interposing  pad  of  muscle  is  also  of 
great  service  in  resection  operations,  as  can  _  be 
well  understood.  Braune  states  that  by  pressing 
the  clavicle  against  the  first  rib  in  the  dead  body 
a  stream  of  injection  in  the  thoracic  duct  can,  in 
some  cases,  be  entirely  arrested.  Behind  the 
clavicle  the  following  structures  may  be  noted; 
viz.,  the  innominate,  subclavian,  and  external 
jugular  veins,  the  subclavian,  suprascapular,  and 
internal  mammary  arteries,  the  cords  of  the 
brachial  plexus,  the  phrenic  nerve  and  nerve  of 
Bell,  the  thoracic  duct,  the  omo-hyoid,  scalene, 
sterno-hyoid  and  sterno-thyroid  muscles,  and  the 
apex  of  the  lung.  The  sternal  end  of  the  bone  is 
not  far  removed  from  the  innominate  or  left 
carotid  artery,  the  vagus  and  recurrent  nerves, 
the  trachea,  and  the  oesophagus. 

These  relations  of  the  clavicle  are  given  to  show 
the  dangers  in  the  way  of  partial  or.  complete 
resections  of  the  bone.  The  difficulties  and  risks 
of  the  operation  increase  as  one  progresses  from 
the  acromial  to  the  sternal  end.  Resection  of  the 
acromial  third  of  the  bone  is  comparatively  easy, 
but  resection  of  the  sternal  portion  is  difficult 
and  dangerous.  The  entire  clavicle  has  been  re- 
moved with  success,  and  the  operation  has  been 
followed  by  less  impairment  of  the  arm  movements 
tt^an  would  be  imagined. 

The  clavicle  forms  the  sole  direct  bony  con- 
nection between  the  upper  limb  and  the  trunk, 
and  in  severe  accidents,  this  connection  being 
broken  through,  it  is  possible  for  the  extremity 
to  be  torn  off  entire.  Thus  Billroth  reports  the 
case  of  a  boy  aged  fourteen,  whose  right  arm,  with 
the  scapula  and  clavicle,  was  so  torn  from  the 
trunk  by  a  machine  accident  that  it  was  only 
attached  by  a  strip  of  skin  two  inches  wide. 
Other  like  cases  of  avulsion  of  the  limb  have  been 
reported. 

Fractures  of  clavicle. — The  clavicle  is  more 


Chap   XI]     EEGION    OF    THE    SHOULDER  221 

frequently  broken  than  is  any  other  single  bone  in 
the  body.  This  frequency  is  explained  by  the  fact 
that  the  bone  is  very  superficial,  is  in  a  part  ex- 
posed to  injury,  is  slender  and  contains  much 
compact  tissue,  is  ossified  at  a  very  early  period 
of  life,  and  above  all  receives  a  large  part  of  all 
shocks  communicated  to  the  upper  extremity.  The 
common  fracture,  that  due  to  indirect  violence,  is 
oblique,  and  very  constant  in  its  position,  viz. 
at  the  outer  end  of  the  middle  third  of  the  bone. 
So  closely  is  the  outer  third  of  the  clavicle  bound 
by  ligaments  to  the  coracoid  and  acromion  pro- 
cesses that  it  may  be  regarded  as  part  of  the 
scapula.  Hence  the  impact  resulting  from  a  fall 
on  the  shoulder  is  transferred  to  the  clavicle  at 
the  junction  of  its  outer  and  middle  thirds.  The 
bone  breaks  at  the  point  where  the  force  is  trans- 
ferred to  the  clavicle  from  the  scapula.  The  posi- 
tion of  the  coraco-clavicular  ligaments  is  no  doubt 
of  the  greatest  import  in  localising  the  fracture 
in  this  position,  since  a  clavicle  experimentally 
subjected  to  longitudinal  compression  does  not 
break  at  this  spot  (Bennett). 

The  displacement  that  occurs  is  as  follows.  The 
inner  fragment  remains  unchanged  in  position,  or 
its  outer  end  is  drawn  a  little  upwards  by  the 
sterno-mastoid.  It  will  be  seen  that  any  action  of 
this  muscle  would  be  resisted  by  the  pectoralis 
major  and  the  rhomboid  ligament.  The  outer  frag- 
ment undergoes  a  threefold  displacement.  (1)  It  is 
carried  directly  do  wti  wards.  This  is  effected  mainly 
by  the  weight  of  the  limb  aided  by  the  pectoralis 
minor,  the  lower  fibres  of  the  pectoralis  major, 
and  the  latissimus  dorsi.  (2)  It  is  carried 
directly  inwards  by  the  muscles  that  pass  from 
the  trunk  to  the  shoulder,  viz.  the  levator  anguli 
scapulae,  the  latissimus  dorsi,  and  especially  by 
the  pectorals.  (3)  The  fragment  is  rotated  in 
such  a  way  that  the  outer  end  projects  forwards, 
the  inner  end  backwards.  This  rotation  is 
brought  about  mainly  by  the  two  pectorals,  as- 
sisted prominently  by  the  serratus  magnus.     The 


222  SUEGICAL    APPLIED    ANATOMY    [Part  III 

normal  action  of  this  latter  muscle  is  to  carry  the 
scapula  forwards,  and  the  clavicle,  acting  as  a 
kind  of  outrigger  to  keep  the  upper  limb  at  a 
proper  distance  from  the  trunk,  moves  forwards 
at  the  same  time  and  keeps  the  scapula  direct. 
When  this  outrigger  is  broken  the  serratus  can  no 
longer  carry  the  scapula  directly  forwards.  The 
bone  tends  to  turn  towards  the  trunk,  and  the 
point  of  the  shoulder  is  therefore  seen  to  move 
inwards  as  well  as  forwards.  The  fragments  in 
this  fracture  must  consequently  overlap,  and  as 
the  displacement  is  difficult  to  remedy,  it  follows 
that  in  no  bone  save  the  femur  is  shortening  so 
uniformly  left  as  after  an  oblique  fracture  of  the 
clavicle.  The  degree  of  shortening  very  seldom 
exceeds  one  inch.  The  deformity  associated  with 
this  fracture  is  well  remedied  when  the  patient 
assumes  the  recumbent  position.  In  this  posture, 
the  weight  of  the  limb  being  taken  off,  the  down- 
ward displacement  is  at  once  remedied.  The 
point  of  the  shoulder  falling  back  also  tends  to 
relieve  in  part  the  inward  displacement,  and  the 
rotation  of  the  outer  fragment  forwards.  It  is 
through  the  scapula,  however,  that  these  two  latter 
displacements  are  in  the  main  removed.  In  the 
recumbent  posture  the  scapula  is  pressed  closely 
against  the  thorax,  with  the  result  that  its  outer 
extremity  (and  with  it,  of  course,  the  outer  frag- 
ment of  the  clavicle)  is  dragged  outwards  and 
backwards.  Some  surgeons,  recognising  this  im- 
portant action  of  the  scapula  in  remedying  the 
displacement  in  these  cases,  strap  the  scapula 
firmly  against  the  trunk,  while  at  the  same  time 
they  elevate  the  arm. 

Fractures  due  to  direct  violence  are  usually 
transverse,  and  may  be  at  any  part  of  the  bone. 
When  about  the  middle  third  they  present  the  dis- 
placement just  described.  When  the  fracture  is 
between  the  conoid  and  trapezoid  ligaments  no 
displacement  is  possible.  When  beyond  these  liga- 
ments, the  outer  end  of  the  outer  fragment  is  car- 
ried forwards  by  the  pectorals  and  serratus,  and 


Chap.  XI]     EEGION    OF    THE    SHOULDER  223 

its  inner  end  is  a  little  drawn  up  by  the  trapezius. 
In  this  fracture  there  is  no  general  displacement 
downwards  of  the  outer  fragment,  since  it  can- 
not move  in  that  direction  unless  the  scapula  go 
with  it,  and  the  scapula  remains  fixed  by  the 
coraco-clavicular  ligaments  to  the  inner  fragment 
of  the  clavicle. 

The  clavicle  may  be  broken  by  muscular  vio- 
lence alone.  Polaillon,  from  a  careful  analysis  of 
the  reported  cases,  concludes  that  the  muscles  that 
break  the  bone  are  the  deltoid  and  clavicular 
part  of  the  great  pectoral.  In  no  case  does  the 
fracture  appear  to  have  been  produced  by  the 
sterno-mastoid  muscle.  The  commonest  movements 
producing  fracture  appear  to  be  violent  move- 
ments of  the  limb  forwards  and  inwards,  or  up- 
wards. These  fractures  are  usually  about  the 
middle  of  the  bone,  and  show  no  displacement 
other  than  that  of  both  fragments  forwards,  i.e. 
in  the  direction  of  the  fibres  of  the  two  muscles 
first  named. 

The  clavicle  is  more  frequently  the  seat  of 
green-stick  fracture  than  is  any  other  bone  in  the 
body.  Indeed,  one-half  of  the  cases  of  broken 
collar-bone  occur  before  the  age  of  five  years. 
This  is  explained  by  the  fact  that  the  bone  is 
ossified  at  a  very  early  period,  and  is  in  a  break- 
able condition  at  a  time  when  most  of  the  other 
long  bones  still  present  much  unossified  cartilage 
in  their  parts.  Moreover,  the  periosteum  of  the 
clavicle  is  unduly  thick,  and  not  very  closely 
attached  to  the  bone,  circumstances  that  greatly 
favour  subperiosteal  fracture. 

A  reference  to  the  relations  of  the  bone  will 
show  that  important  structures  may  be  wounded 
in  severe  fractures  associated  with  much  displace- 
ment and  with  sharp  fragments.  Several  cases 
are  reported  of  paralysis  of  the  upper  limb  (as  a 
rule  incomplete)  following  upon  fracture  of  this 
bone.  In  some  _  cases  this  symptom  was  due  to 
actual  compression  or  tearing  of  some  of  the  great 
nerve  cords  by  the  displaced  fragments.     In  other 


224  SURGICAL    APPLIED    ANATOMY  [Part  III 

cases  the  nerve  injury,  while  due  to  the  original 
accident,  was  yet  independent  of  the  broken  clavi- 
cle. Paralysis  of  the  biceps,  brachialis  anticus, 
and  supinator  longus,  muscles  supplied  through 
the  upper  cord,  may  result  from  heavy  weights 
being  carried  on  the  shoulder.  Cases  are  reported 
of  wound  of  the  subclavian  artery,  of  the  sub- 
clavian vein,  of  the  internal  jugular  vein,  and  of 
the  acromio-thoracic  artery.  -In  several  instances 
the  fracture  has  been  associated  with  wound  of  the 
lung,  with  or  without  a  fracture  of  the  upper  ribs. 

The  clavicle  begins  to  ossify  before  any  bone  in 
the  body.  At  birth  the  entire  shaft  is  bony,  the 
two  ends  being  still  cartilaginous.  The  bone  has 
one  epiphysis  for  its  sternal  end  that  appears  be- 
tween the  eighteenth  and  twentieth  year,  and  joins 
the  shaft  about  twenty-five.  It  is  a  mere  shell,  is 
closely  surrounded  by  the  ligaments  of  the  sternal 
joint,  and  cannot,  therefore,  be  well  separated  by 
accident.'""  In  cases  where  the  clavicle  is  described 
as  congenitally  absent,  the  membrane-formed 
part  of  the  bone  is  represented  by  a  ligamentous 
cord ;  the  cartilage-formed  extremities  are  repre- 
sented by  bony  nodules. 

Steriio-clavicular  joint.  —  Although  this  is 
the  onlv  articulation  that  directly  connects  the 
upper  limb  with  the  trunk,  yet  it  is  possessed  of 
such  considerable  strength  that  luxation  at  the 
joint  is  comparatively  rare.  The  amount  of  move- 
ment in  the  joint  deDends  to  a  great  extent  upon 
the  lack  of  adaptability  between  the  facets  on  the 
sternum  and  the  sternal  end  of  the  clavicle.  The 
disproportion  between  these  parts  is  maintained 
by  the  interarticular  cartilage,  which  reproduces 
onlv  the  outline  of  the  clavicular  surface.  The 
cavity  of  the  joint  is  V-shaped,  since  the  clavicle 
only  touches  the  socket  at  its  inferior  angle  when 
the    arm   hangs   by   the    side.     When    the   arm    is 

*  Mr.  Heath  {Lancet,  Nov.  is,  1882)  reports  a  case  which  is  probably 
vrainue.    Tt  concerns  a  lad,  aged  14,  who.  when  in  the  act  of  bowling  at 

cricket,  tore  the  clavicle  away  from  its  epiphyseal  cartilage,  which 
remained  in  sitv.  The  muscle  producing  the  accident  was  apparently  the 
pectoralis  major. 


Chap.  XI]     REGION    OF    THE    SHOULDER  225 

elevated,  however,  the  two  bones  are  brought  in 
more  immediate  contact,  and  the  joint  cavity  be- 
comes a  mere  slit.  Thus,  in  disease  of  this  articu- 
lation it  will  be  found  that  of  all  movements  of 
the  joint  the  movement  of  the  limb  upwards  is  the 
most  constant  in  producing  pain.  The  joint  is 
supplied  by  the  suprasternal  nerve. 

The  movements  permitted  at  this  joint  are 
limited,  owing  to  the  anterior  and  posterior 
sterno-clavicular  ligaments  being  moderately 
tense  in  all  positions  of  the  clavicle.  Movement 
forwards  of  the  clavicle  on  the  sternum  is  checked 
by  the  posterior  ligament,  and  resisted  by  the  an- 
terior ligament.  This  latter  ligament  is  more  lax 
and  less  substantial  than  is  the  posterior  band. 
Its  weakness  serves  in  part  to  explain  the  fre- 
quency of  the  dislocation  forwards. 

Movement  of  the  clavicle  backwards  on  the 
sternum  is  checked  by  the  anterior  ligament,  while 
the  passage  of  the  head  of  the  bone  is  resisted  by 
the  powerful  posterior  band.  The  movement  is 
also  opposed  by  the  rhomboid  ligament.  To  pro- 
duce, therefore,  a  dislocation  backwards  consider- 
able force  must  be  used.  Movement  of  the  clavicle 
upwards  on  the  sternum  is  checked  by  the  rhom- 
boid ligament,  the  interclavicular  ligament,  the 
interarticular  cartilage,  and  in  a  less  direct  man- 
ner by  the  two  remaining  ligaments  of  the  joint. 
Thus  it  happens  that  dislocation  upwards  is  the 
least  common  of  the  luxations  at  this  articulation. 

Disease  of  the  sterno-clavicular  joint. — 
This  articulation  is  really  divided  into  two  joints 
by  the  interarticular  cartilage,  each  being  pro- 
vided with  a  distinct  synovial  membrane. 

These  joints  are  liable  to  the  ordinary  maladies 
of  joints,  and  it  would  appear  that  the  disease 
may  commence  in,  and  be  for  some  time  limited 
to,  only  one  of  the  synovial  sacs.  In  time  the 
whole  articulation  usually  becomes  involved,  but 
even  in  advanced  cases  the  mischief  is  sometimes 
restricted  to  the  synovial  cavity  on  one  side  of  the 
cartilage.  According  to  some  authors,  this  joint 
p 


226  SURGICAL    APPLIED    ANATOMY  [Part  III 

is  more  frequently  involved  in  pysemia  than  is  any 
other.  When  effusion  has  taken  place  into  the 
sterno-clavicular  joint,  and  especially  after  sup- 
puration has  ensued,  the  swelling  usually  makes 
itself  evident  in  front,  owing  to  the  fact  that  the 
anterior  sterno-clavicular  ligament  is  the  thinnest 
and  least  resisting  of  the  ligamentous  structures 
about  the  articulation.  For  the  same  reason  the 
pus  usually  escapes  from  the  anterior  surface 
when  it  discaarges  itself  spontaneously.  It  may, 
however,  make  an  opening  for  escape  through  the 
posterior  ligament,  and  in  these  circumstances  has 
found  its  way  into  the  mediastinum.  The  rela- 
tions of  this  joint  to  the  great  vessels  at  the  root 
of  the  neck  should  be  borne  in  mind.  In  one  case 
reported  by  Hilton  a  large  abscess  formed  in  the 
articulation,  and  the  collection,  receiving  pulsa- 
tions from  the  subjacent  artery  (the  innominate 
or  right  subclavian),  was  supposed  at  one  time  to 
be  an  aneurism.  It  is  remarkable  that  disease  of 
this  joint  never  leads  to  ankylosis.  This  circum- 
stance may  be  explained  (1)  by  the  constant 
slight  movement  in  the  part,  which  prevents  the 
diseased  structures  from  being  kept  at  rest,  (2) 
by  the  occasional  persistence  of  the  interarticular 
cartilage,  and  (3)  by  the  utter  lack  of  adapta- 
bility of  the  two  bony  surfaces  involved. 

Dislocations  of  the  sterno-clavicular  joint. 
— The  clavicle  may  be  dislocated  from  the  sternum 
in  one  of  three  directions,  which,  given  in  order 
of  frequency,  are  :  (1)  forwards,  (2)  backwards, 
(3)  upwards.  The  relative  frequency  of  these  dis- 
locations can  be  understood  from  what  has  been 
already^  said  as  to  the  action  of  the  ligaments  in 
restricting  movements.  The  displacement  for- 
wards involves  entire  rupture  of  the  capsule,  and  I 
more  or  less  damage  to  the  rhomboid  ligament. 
The  head  of  the  bone,  carrying  with  it  the  sterno- 
mastoid,  rests  on  the  front  of  the  manubrium. 
The  dislocation  backwards  may  be  due  to  direct 
or  indirect  violence,  and  has  occurred  spontane- 
ously in  connection    with  the  chest  deformity  in 


Chap.  XI]     REGION    OF    THE    SHOULDER  227 

Pott's  disease.  The  capsule  is  entirely  torn,  as  is 
also  the  rhomboid  ligament.  The  head  is  found 
in  the  connective  tissue  behind  the  sterno-hyoid 
and  sterno-thyroid  muscles.  In  this  position  it 
may  cause  severe  dyspnoea,  or  dysphagia,  by 
pressure  upon  the  trachea  or  gullet.  It  may  so 
compress  the  subclavian  artery  as  to  arrest  the 
pulse  at  the  wrist,  or  so  occlude  the  innominate 
vein  as  to  produce  semi-coma  (Fig.  39,  p.  218). 
In  one  case  the  head  of  the  bone  had  to  be  ex- 
cised to  relieve  a  troublesome  dysphagia.  In  the 
luxation  upwards,  due  usually  to  indirect  vio- 
lence, the  head  rests  on  the  upper  border  of  the 
sternum  between  the  sterno-mastoid  and  sterno- 
hyoid muscles.  It  involves  more  or  less  complete 
tearing  of  all  the  ligaments  of  the  joint,  together 
with  avulsion  of  the  interarticular  nbro-cartilage. 

The  non-adaptability  of  the  joint  surfaces  in 
this  part  serves  to  explain  the  ease  with  which 
these  luxations  are  usually  reduced,  and  the  diffi- 
culty of  retaining  the  clavicle  in  position  after  it 
is  replaced. 

4 croon io-cl a vicul a .r  joint. — This  articulation 
is  shallow,  and  the  outlines  of  the  two  bones  that 
enter  into  its  formation  are  such  that  no  obstacle 
is  offered  to  the  displacement  of  the  clavicle  from 
the  acromion.  The  joint,  indeed,  depends  for  its 
strength  almost  entirely  upon  its  ligaments.  The 
plane  of  the  joint  would  be  represented  by  a  line 
drawn  from  above  downwards  and  inwards  be- 
tween the  two  bones.  This  inclination  of  the  joint 
surfaces  serves  to  explain  the  fact  that  the  usual 
luxation  of  this  part  takes  the  form  of  a  displace- 
ment of  the  clavicle  upwards  on  to  the  acromion. 
The  capsule  that  surrounds  the  joint  is  lax  and 
feeble,  and  it  is  partly  from  its  comparative  thin- 
ness that  effusion  into  this  joint,  when  it  is  the 
seat  of  disease,  makes  itself  so  soon  visible.  The 
joint,  however,  depends  mainly  for  its  strength 
upon  the  powerful  conoid  and  trapezoid  liga- 
ments. The  effects  of  shock  at  this  joint  are  les- 
sened by  the  presence  of  a  partial  nbro-cartilage 


228  SURGICAL    APPLIED    ANATOMY  [Part  III 

which  projects  between  the  bones  from  the  upper 
part  of  the  capsule. 

As  the  movements  permitted  in  this  joint  may 
be  impaired  by  accident  or  disease,  it  is  well  to 
note  the  part  the  articulation  takes  in  the  move- 
ments of  the  extremity.  The  scapula  (and  with  it, 
of  course,  the  arm),  as  it  glides  forwards  and 
backwards  upon  the  thorax,  moves  in  the  arc  of  a 
circle  whose  centre  is  at  the  sterno-clavicular 
joint,  and  whose  radius  is  the  clavicle.  As  the 
bone  moves  forwards  it  is  important,  for  reasons 
to  be  immediately  given,  that  the  glenoid  cavity 
should  also  be  directed  obliquely  forwards.  This 
latter  desirable  condition  is  brought  about  by 
means  of  the  acromio-clavicular  joint.  Without 
this  joint  the  whole  scapula  as  it  passed  forwards 
with  the  outer  end  of  the  clavicle  would  precisely 
follow  the  line  of  the  circle  above  mentioned,  and 
the  glenoid  cavity  would  look  in  an  increasingly 
inward  direction.  It  is  essential  that  the  surface 
of  the  glenoid  cavity  should  be  maintained  as  far 
as  possible  at  right  angles  to  the  long  axis  of  the 
humerus.  When  these  relations  are  satisfied,  the 
humerus  has  the  support  behind  of  a  stout  sur- 
face of  bone,  and  it  is  partly  to  obtain  the  value 
of  this  support  that  the  boxer  strikes  out  from 
the  side,  i.e.  with  his  humerus  well  backed  up  by 
the  scapula.  If  there  were  no  acromio-clavicular 
joint  the  glenoid  fossa  would  offer  little  support 
to  the  humerus  when  the  limb  was  stretched  for- 
wards, and  a  blow  given  with  the  limb  in  that 
position,  or  a  fall  upon  the  hand  under  like  con- 
ditions, would  tend  to  throw  the  humerus  against 
the  capsule  of  the  shoulder  joint,  and  so  produce 
dislocation.  Normally,  therefore,  as  the  scapula 
and  arm  advance,  the  angle  between  the  acromion 
and  the  adjacent  portion  of  the  clavicle  becomes 
more  and  more  acute,  and  the  glenoid  fossa  is 
maintained  with  a  sufficiently  forward  direction 
to  give  substantial  support  to  the  humerus. *     It 

*  For  an   excellent  account    of  the   mechanism   of   these  joints  see 
Morris's  "  Anatomy  of  the  Joints,"  p.  202  et  se</.     1879. 


Chap.  XI]     REGION   OF   THE   SHOULDER  229 

will  thus  be  seen  that  rigidity  of  this  little  joint 
may  be  a  cause  of  insecurity  in  the  articulation 
of  the  shoulder,  and  of  weakness  in  certain  move- 
ments of  the  limb. 

Dislocations  of  the  acroinio-  clavicular 
joint.  —  The  clavicle  may  be  displaced  upwards 
on  to  the  acromion  or  downwards  beneath  it. 
Polaillon  has  collected  thirty-eight  cases  of  the 
former  luxation,  and  six  only  of  the  latter.  This 
disproportion  is,  in  the  main,  explained  by  the 
direction  of  the  articulating  surfaces  of  the  joint. 
Both  luxations  are  usually  due  to  direct  violence. 
The  dislocation  upwards  is  very  commonly  only 
partial,  and  is  associated  only,  with  stretching 
and  some  trifling  rupture  of  ligaments.  In  the 
complete  form,  where  the  end  of  the  clavicle  rests 
entirely  upon  the  acromion,  there  is  rupture,  not 
only  of  the  capsule,  but  also  to  a  greater  or  less 
extent  of  the  coraco-clavicular  ligaments.  In  the 
complete  dislocation  downwards,  also,  there  is  a 
rupture  of  the  capsule,  with  extensive  tearing 
of  the  conoid  and  trapezoid  ligaments.  These 
luxations  are  usually  easily  reduced,  but  it 
will  be  understood,  from  the  direction  of  the 
articular  surfaces,  that  in  the  displacement  up- 
wards it  is  very  difficult  to  retain  the  clavicle  in 
situ  when  once  reduced. 

Scapula.  —  At  the  posterior  aspect  of  the  bone 
the  muscles  immediately  above  and  below  the  spine 
are  somewhat  precisely  bound  down  by  the  deep 
fascia.  Thus,  the  supraspinatus  muscle  is  en- 
closed in  a  fascia  that,  being  attached  to  the  bone 
all  round  the  origin  of  the  muscle,  forms  a  cavity 
open  only  towards  the  insertion  of  the  muscle. 

The  infraspinatus  and  teres  minor  muscles  are 
also  enclosed  in  a  distinct,  but  much  denser,  fascia 
that  is  attached  to  the  bone  beyond  these  muscles, 
and  blends  in  front  with  the  deltoid  sheath  so  as 
to  form  a  second  enclosed  space.  The  arrange- 
ment of  these  fasciae  serves  to  explain  the  trifling 
amount  of  ecchymosis  that  usually  follows  upon 
fractures  of  the  scapular  blade.     The  extravasa- 


230  SURGICAL    APPLIED    ANATOMY  [Part  III 

tion  of  blood  about  the  fracture  is  bound  down 
by  the  fasciae  over  these  muscles,  and  is  unable, 
therefore,  to  reach  the  surface. 

Movements  of  the  scapula. — In  lifting  the 
arm  from  the  side  to  a  vertical  position  over 
the  head,  the  scapula  undergoes  a  free  rota- 
tory movement,  its  vertebral  border  passing 
from  an  approximately  vertical  to  an  approxi- 
mately horizontal  position.  At  the  commence- 
ment of  the  movement,  until  the  arm  has  as- 
cended 35  degrees  from  the  side,  the  angle  of  the 
scapula  is  practically  stationary ;  during  this 
stage  the  scapula  is  fixed  and  maintained  in  posi- 
tion by  the  trapezius,  rhomboids,  and  serratus 
magnus.  If  the  trapezius  is  paralysed,  as  may 
result  from  accidental  section  of  the  spinal  acces- 
sory nerve  in  removing  glands  from  the  neck,  the 
angle  and  vertebral  border  project  backwards, 
under  the  weight  of  the  raised  arm.  When  the 
arm  passes  beyond  35  degrees,  the  serratus  magnus 
comes  into  action,  and  the  angle  of  the  scapula 
moves  rapidly  forwards.  If  the  nerve  to  this 
muscle  be  paralysed  (the  nerve  of  Bell  from 
5,  6,  7  c.)  or  if  its  antagonists — the  rhomboids — 
which  are  also  then  in  action,  be  paralysed  (nerve 
from  5  a),  then  the  angle  and  posterior  border  of 
the  scapula  become  prominent  or  "  winged  " — 
evidence  of  the  paralysis  of  these  muscles.  Thus 
"winging"  of  the  scapula  at  the  commencement 
of  the  movement  indicates  paralysis  of  the  trape- 
zius ;  if  it  occurs  after  the  movement  is  well  begun, 
then  the  serratus  magnus  is  affected. 

Fractures  of  the  scapula,  and  especially  of 
the  body  of  the  bone,  are  not  common,  owing  to  the 
mobility  of  the  part  and  the  thick  muscles  that 
cover  in  and  protect  its  thinner  portions.  It  rests 
also  upon  a  soft  muscular  pad,  and  derives,  no 
doubt,  additional  security  from  the  elasticity  of 
the  ribs. 

The  most  common  lesion  is  a  fracture  of  the 
acromion  process.  This  is  often  but  a  separation 
of  the  epiphysis.     There  are  two,  sometimes  three, 


Chap.  XII     REGION    OF    THE    SHOULDER  231 

epiphyseal  centres  for  the  acromion.  Ossification 
appears  in  them  about  puberty,  and  the  entire 
epiphysis  joins  with  the  rest  of  the  bone  from  the 
twenty-second  to  the  twenty-fifth  year.  Several 
cases  of  supposed  fracture  of  the  acromion  united 
by  fibrous  tissue  are  probably  but  instances  of  an 
imperfectly-united  epiphysis,  and  may  have  been 
independent  of  injury.  In  five  bodies  out  of  forty 
Symington  found  the  acromial  epiphysis  united 
to  the  spine  by  a  fibrous  union,  and  from  the 
statistics  of  other  observers  it  appears  that  this 
is  the  case  in  quite  10  per  cent,  of  adults.  In 
fractures  of  the  process  much  displacement  is 
quite  uncommon,  owing  to  the  dense  fibrous  cover- 
ing the  bone  derives  from  the  two  muscles  attached 
to  it.  This  dense  periosteum  also  explains  the 
circumstance  that  many  fractures  are  incomplete 
and  crepitus  is  often  absent.  When  the  fracture 
is  in  front  of  the  clavicular  joint,  displacement  of 
the  arm  is  impossible.  When  it  involves  the  joint, 
a  dislocation  of  the  collar  bone  is  common.  When 
behind  the  joint,  the  arm,  having  lost  its  sup- 
port from  the  thorax,  is  displaced  in  somewhat  the 
same  way  as  obtains  in  the  common  fracture  of 
the  clavicle.  The  coracoid  process  may  present  a 
genuine  fracture,  or  may  be  separated  as  an 
epiphysis.  As  an  epiphysis,  it  joins  the  main 
bone  about  the  age  of  seventeen.  The  supra- 
glenoid  tubercle,  from  which  the  long  head  of  the 
biceps  takes  its  origin,  is  part  of  the  coracoid 
epiphysis.  In  spite  of  the  powerful  muscles  at- 
tached to  it,  the  displacement  is  usually  slight, 
inasmuch  as  the  coraco-clavicular  ligaments  are 
seldom  torn.  These  ligaments,  it  may  be  noted, 
are  attached  to  the  base  of  the  process.  In  some 
few  cases  the  process  has  been  torn  off  by  mus- 
cular violence. 

Among  the  more  usual  fractures  of  the  body  of 
the  scapula  is  a  transverse  or  oblique  fracture 
of  its  blade  below  the  spine.  Owing  to  the  infra- 
spinatus, subscapulars,  and  other  muscles  being- 
attached  to  both   fragments,    none  but  a  trifling 


232  SUKGICAL    APPLIED    ANATOMY  [Part  III 

displacement  is  usual.  A  fracture  may  occur 
through  the  surgical  neck.  The  surgical  neck  is 
vepresented  by  a  narrowed  part  of  the  bone  be- 
hind the  glenoid  fossa,  and  in  the  line  of  the 
suprascapular  notch.  The  smaller  fragment  will, 
therefore,  include  the  coracoid  process,  the  larger, 
the  acromion.  The  amount  of  deformity  in  these 
cases  depends  upon  whether  the  coraco-clavicular 
and  acromio-clavicular  ligaments  are  entire  or 
torn.  If  they  be  torn,  the  smaller  fragment  and 
the  entire  limb  are  displaced  downwards,  and  the 
injury  somewhat  resembles  a  subglenoid _ disloca- 
tion. From  this,  however,  it  is  distinguished  by 
the  crepitus,  by  the  ease  with  which  the  deformity 
is  removed  and  the  equal  ease  with  which  it  re- 
turns, by  the  position  of  the  head  of  the  humerus 
in  regard  to  the  glenoid  fossa,  and  by  the  con- 
spicuous fact  that  the  coracoid  process  is  displaced 
downwards  with  the  limb. 

Tumours  of  various  kinds  grow  from  the 
scapula  and  mainly  from  the  spongy  parts  of  the 
bone,  viz.  the  spine,  the  neck,  and  the  inferior  angle. 
The  bone  may  be  removed  entire,  with  or  without 
amputation  of  the  upper  limb.  An  interscapulo- 
thoracic  amputation  is  usually  performed  for 
malignant  tumours  which  involve  structures  in 
the  neighbourhood  of  the  shoulder-joint.  In  this 
operation  the  upper  extremity,  including  the 
scapula  and  the  clavicle  beyond  the  origin  of  the 
sterno-mastoid,  is  removed.  An  elliptical  incision 
is  made  in  front  and  behind  the  shoulder,  the 
upper  end  of  the  ellipse  lying  on  the  clavicle,  the 
lower  at  the  angle  of  the  scapula.  The  operation 
is  commenced  at  the  clavicle  so  as  to  secure  the 
axillary  vessels.  The  artery  is  tied  before  the 
vein  so  that  the  limb  may  continue  to  empty  its 
blood  into  the  circulation.  The  main  vessels  to 
be  noted  in  connection  with  this  operation  are  the 
suprascapular  at  the  superior  border  of  the  bone, 
the  posterior  scapular  about  the  vertebral  border, 
the  subscapular  running  along  the  lower  border 
of  the  subscapulars  muscle,  the  dorsalis  scapulae 


Chap.  XI]     REGION    OF    THE    SHOULDER  233 

crossing  the  axillary  edge  of  the  bone,   and  the 
acromial  branches  of  the  acromio-thoracic  artery. 

The  axilla. —The  axilla  may  be  regarded  sur- 
gically as  a  passage  between  the  neck  and  the 
upper  limb.  Axillary  tumours  and  abscesses  may 
spread  up  into  the  neck,  and  in  like  manner  cer- 
vical growths  and  purulent  collections  may  extend 
to  the  armpit.  The  skin  forming  the  base  of  the 
axilla  is  provided  with  many  short  hairs  and 
with  numerous  sebaceous  and  sudoriparous  glands. 
In  this  integument  small  superficial  abscesses  are 
often  met  with,  that  arise  usually  from  suppu- 
ration of  these  glandular  structures,  and  that  are 
brought  about  by  the  friction  of  the  skin  against 
the  clothing.  Owing  to  the  tendency  of  the  axil- 
lary integument  to  become  chafed  and  inflamed 
under  friction,  the  axilla  is  not  a  good  locality  to 
select  for  the  use  of  the  mercurial  inunction  as 
applied  in  syphilis.  Beneath  the  skin  and  super- 
ficial fasciae  is  the  axillary  fascia,  and  beyond  this 
membrane  is  the  axillary  space.  The  connective 
tissue  with  which  the  axillary  space  is  mainly 
occupied  is  very  loose,  and,  while  this  laxity 
favours  greatly  the  free  movement  of  the  arm,  it 
at  the  same  time  permits  of  the  formation  of  large 
purulent  collections  and  immense  extravasations 
of  blood. 

It  is  important  to  remember  the  disposition  of 
the  fasciae  about  this  region.  There  are  three 
layers  principally  concerned.  (1)  The  deep  pec- 
toral fascia  that  covers  in  and  encloses  the  pector- 
alis  major.  (2)  The  clavi-pectoral  fascia  that, 
adherent  above  to  the  clavicle,  fills  in  the  space 
between  that  bone  and  the  pectoralis  minor,  then 
splits  to  invest  this  muscle,  and  joins  the  deep 
pectoral  layer  at  the  anterior  fold  of  the  axilla 
to  form  with  it  the  axillary  fascia.  The  upper 
part  of  this  fascia  is  generally  known  as  the  costo- 
coracoid  membrane.  The  whole  membrane  is  some- 
times known  also  as  the  "  suspensory  ligament  of 
the  axilla,"  since  it  draws  up  the  axillary  fascia 
towards  the  clavicle,  and  is  mainly  instrumental 


234  SURGICAL    APPLIED    ANATOMY  [Part  Til 

in  producing  the  "  hollow  "  of  the  armpit.  (3) 
The  axillary  fascia  that  is  formed  by  the  union 
of  the  two  preceding  fasciae,  and  stretches  across 
the  base  of  the  axilla  from  its  anterior  to  its  pos- 
terior fold.  It  is  thinnest  under  the  axillary 
hairs. 

Abscess  about  the  axillary  region  may  be 
considered  (1)  when  it  is  beneath  the  pectoralis 
major,  or  between  the  two  pectoral  muscles,  and 
(2)  when  it  is  beneath  the  pectoralis  minor  and 
clavi-pectoral  fascia,  and  therefore  in  the  axillary 
space.  (1)  An  abscess  in  this  situation  is  placed 
between  the  deep  pectoral  and  the  clavi-pectoral 
fasciae,  the  latter  separating  it  from  the  axillary 
space.  Such  an  abscess  undermines  the  great  pec- 
toral, and  tends  to  present  either  at  the  anterior 
margin  of  the  axilla,  or  in  the  groove  between  the 
great  pectoral  and  deltoid  muscles,  being  guided 
thither  by  the  attachment  of  the  fasciae.  (2)  A 
purulent  collection  in  the  axilla  may  soon  fill  that 
space  and  distend  it  entirely.  Its  progress  to- 
wards the  skin  is  arrested  by  the  axillary  fascia, 
its  progress  backwards  by  the  serratus  magnus 
muscle,  which,  by  its  attachment  to  the  scapula, 
hermetically  closes  the  axillary  space  behind.  In 
front  the  advance  of  the  abscess  is  prevented  by 
the  pectoral  muscles  and  clavi-pectoral  fascia, 
while  on  the  inner  side  is  the  unyielding  thorax, 
and  on  the  outer  side  the  upper  limb.  The 
abscess,  therefore,  as  it  fills  the  axilla  pushes  for- 
wards the  pectoralis  major,  more  or  less  obliter 
ates  the  hollow  of  the  armpit,  thrusts  back  the 
scapula,  and  widens  the  angle  between  the  serra- 
tus magnus  and  the  subscapularis  muscles.  There 
is  a  great  tendency,  therefore,  for  unrelieved  ab- 
scesses to  extend  upwards  into  the  neck,  that  being 
the  direction  in  which  the  least  amount  of  resist- 
ance is  encountered.  From  the  neck  the  purulent 
collection  may  extend  into  the  mediastinum.  In 
one  case  an  axillary  abscess,  set  up  by  shoulder- 
joint  disease,  perforated  the  first  intercostal  space 
and  set  up  fatal  pleurisy. 


Chap.  XII    REGION    OF    THE    SHOULDER  235 

In  opening  an  axillary  abscess,  and,  indeed,  in 
most  incisions  into  this  space,  the  knife  should 
be  entered  at  the  centre  of  the  floor  of  the  axilla, 
i.e.  midway  between  the  anterior  and  posterior 
margins,  and  near  to  the  inner  or  thoracic  side 
of  the  space.  The  vessel  most  likely  to  be  damaged 
by  an  indiscreet  incision  are  the  subscapular, 
running  along  the  lower  border  of  the  .subscapu- 
lars muscle ;  the  long  thoracic,  following  the 
lower  border  of  the  small  pectoral ;  and  the  main 
vessels  lying  close  to  the  humerus.  The  knife,  if 
properly  entered,  should  be  midway  between  the 
two  first-named  vessels,  and  quite  away  from  the 
main  trunks.  There  is  an  artery  (the  external 
mammary)  that  sometimes  comes  off  as  the  lowest 
branch  of  the  axillary  trunk,  and  crosses  the 
middle  of  the  axilla,  to  be  distributed  to  the 
thorax  below  the  long  thoracic.  This  vessel  would 
probably  be  wounded  in  the  incision  above  named. 
The  artery  is,  however,  very  inconstant,  is  small, 
and  is  not  far  below  the  surface.  It  is  usually 
met  with  in  female  subjects. 

Lymphatic  glands. — The  axillary  glands  are 
numerous,  and  of  much  surgical  importance. 
They  may  be  arranged  in  four  sets.  (1)  The 
greater  number  are  placed  to  the  inner  side  of 
the  axillary  vein  beneath  the  axillary  tuft  of 
hair.  This  centred  set  of  glands  receives  the 
lymph  from  the  upper  extremity  and  breast.  Pain 
in  the  axilla  which  follows  whitlow  or  any  septic 
infection  of  the  arm  is  due  to  inflammation  of 
this  group,  which  is  pierced  by  the  intercosto- 
humeral  nerve.  (2)  The  deep  axillary  set  lies 
along  the  axillary  vessels.  It  receives  the  lymph 
from  the  central  set  and  becomes  continuous  with 
the  lower  deep  cervical  glands  in  the  subclavian 
triangle  (Fig.  35,  p.  190).  (3)  Other  glands  lie 
upon  the  serratus  magnus  muscle  on  the  thoracic 
side  of  the  axilla,  and  just  behind  the  lower  bor- 
der of  the  pectoral  muscles.  They  receive  the 
lymphatics  from  the  front  of  the  chest,  the  princi- 
pal lymph  vessels  of  the  breast,  and  the  superficial 


236  SURGICAL    APPLIED    ANATOMY  [Part  III 

lymphatics  of  the -abdomen  as  low  down  as  the 
umbilicus.  Their  efferent  vessels  for  the  most  part 
pass  on  to  join  the  central  set  of  glands.  These 
glands  will  be  the  first  to  be  enlarged  in  certain 
breast  affections,  and  after  blistering  and  other 
superficial  inflammations,  etc.,  of  the  chest  and 
upper  abdomen.  Paulet  has  seen  them  affected 
in  inflammation  of  the  hand.  The  axillary  pro- 
cess of  the  female  breast  is  in  contact  with  this 
set.  (4)  The  remaining  glands  are  situated  at  the 
back  of  the  axilla,  along  the  subscapular  vessels. 
They  are  joined  by  the  lymphatics  from  the  back. 

It  may  here  be  convenient  to  note  that  one  or 
two  glands  are  commonly  found  in  the  groove 
between  the  deltoid  and  pectoralis  major  muscles. 
They  receive  some  vessels  from  the  outer  side  of 
the  arm  and  a  part  of  the  shoulder  and  breast. 
The  superficial  lymphatics  over  the  upper  part  of 
the  deltoid  go  to  the  cervical  glands  (Tillaux), 
over  the  lower  half  to  the  axilla.  The  lymphatics 
from  the  supraspinous  fossa  follow  the  supra- 
scapular artery,  and  join  the  lowest  cervical 
glands.  The  superficial  lymphatics  of  the  back 
that  converge  to  the  axilla  are  derived  from  the 
neck  over  the  trapezius  muscle,  and  from  the 
whole  dorsal  and  lumbar  regions  as  far  down  as 
the  iliac  crest. 

The  complete  removal  of  axillary  glands  is 
an  operation  frequently  undertaken.  It  will  be 
understood  from  their  position  that  these  bodies, 
when  diseased,  are  very  apt  to  become  adherent 
to  the  axillary  vessels,  and  especially  to  the  vein. 
The  latter  vessel  has  frequently  been  wounded  or 
excised  during  the  removal  of  gland  tumours,  and 
in  one  case  at  least  the  artery  was  accidentally 
cut  (Holmes). 

The  axillary  vessels. — The  axillary  vein  is 
formed  by  the  union  of  the  basilic  with  the  two 
vense  comites  of  the  brachial  artery.  This  union 
commonly  takes  place  at  the  lower  border  of  the 
pectoralis  minor  muscle,  and  the  vein  is  therefore 
shorter  than  the  artery.     Sometimes  the  vein  does 


Cimp.  xij      REGION    OF    THE    SHOULDER  237 

not  exist  as  a  single  trunk  until  just  below  the 
clavicle.  This  condition,  when  it  exists,  is  very 
unfavourable  to  operations  upon  the  artery,  as 
many  transverse  branches  cross  that  vessel  to  unite 
the  veins  that  lie  on  either  side  of  it.  The  axil- 
lary vein,  being  comparatively  near  the  heart,  is 
readily  influenced  as  regards  its  contained  blood 
by  the  inspiratory  movement.  Thus  it  happens 
that,  in  many  instances  of  wound  of  the  vessel  or 
of  its  larger  tributaries,  air  has  been  drawn  into 
the  venous  canal  and  death  has  ensued.  The  en- 
trance of  air  into  the  main  vein  is  perhaps  aided 
by  the  circumstance  that  the  costo-coracoid  mem- 
brane (upper  part  of  clavi-pectoral  fascia)  is  ad- 
herent to  the  vessel,  and  thus  tends  to  maintain  it 
in  a  patent  condition  when  wounded.  This  con- 
nection with  the  fascia  is  supposed  by  some  to 
account  in  part  for  the  furious  bleeding  that 
occurs  from  this  vein  when  it  is  divided. 

The  vein  is  more  often  wounded  than  is  the 
artery,  it  being  larger,  more  superficial,  and  so 
placed  as  to  more  or  less  overlap  the  arterial 
trunk.  On  the  other  hand,  in  injury  to  the  vessel 
by  traction,  as,  for  example,  in  reducing  disloca- 
tions, the  artery  suffers  more  frequently  than  the 
vein.  In  all  positions  of  the  upper  limb  the 
artery  keeps  to  the  outer  angle  of  the  axillary 
space.  The  relation  of  the  vein,  however,  to  the 
first  part  of  the  axillary  artery,  the  part  above 
the  pectoralis  minor,  is  modified  by  the  position 
of  the  limb.  Thus,  when  the  arm  hangs  by  the 
side  the  vein  is  to  the  inner  side  of  the  artery, 
and  a  little  in  front  of  it,  but  when  the  limb  is 
at  a  right  angle  with  the  trunk  the  vein  is  drawn 
so  far  in  front  of  the  artery  as  to  almost  entirely 
conceal  that  vessel. 

Aneurism  is  very  frequent  in  the  axillary 
artery,  a  fact  to  be  explained  by  the  nearness  of 
the  vessel  to  the  heart,  by  the  abrupt  curve  it  pre- 
sents, by  its  susceptibility  to  frequent  and  exten- 
sive movements,  and  by  its  liability  to  share  in  the 
many  lesions  of  the  upper  limb.     In  violent  and 


238  SURGICAL    APPLIED    ANATOMY  [Part  III 

extreme  movements  of  the  limb  the  artery  may  be 
more  or  less  torn,  especially  if  its  walls  are 
already  diseased 

In  ligaturing  the  first  part  of  the  axillary 
artery  it  is  well  to  note  that  the  pectoralis  major 
has  sometimes  a  cellular  interval  between  two 
planes  of  muscle  fibre,  and  this  may  be  mistaken 
for  the  space  beneath  it  (Heath).  If  the  pector- 
alis minor  has  an  origin  from  the  second  rib,  it 
may  more  or  less  entirely  cover  the  artery  and  re- 
quire division.  The  cord  of  the  brachial  plexus 
nearest  to  the  artery  may  be  mistaken  for  that 
vessel,  or  easily  included  in  a  ligature  intended 
for  it.  A  ready  guide  to  the  axillary  vessels  in 
this  operation  is  to  follow  the  cephalic  vein.  The 
anterior  internal  thoracic  nerve  appears  between 
the  vein  and  artery  as  it  passes  to  the  pectoralis 
minor.  It  also  may  be  useful  occasionally  as  a 
guide. 

In  applying  a  ligature  to  the  third  part  of  the 
artery,  it  should  be  borne  in  mind  that  a  mus- 
cular slip  sometimes  crosses  the  vessels  obliquely, 
passing  from  the  latissimus  dorsi  to  join  the  pec- 
toralis major,  coraco-brachialis,  or  biceps  mus- 
cles. This  slip  may  give  rise  to  confusion  during 
the  operation,  and  may  be  mistaken  for  the 
coraco-brachialis. 

Brachial  plexus. —  When  the  shoulder  is  de- 
pressed the  upper  and  middle  trunks  of  the 
brachial  plexus,  formed  by  the  fifth,  sixth,  and 
seventh  cervical  nerves,  can  be  distinctly  felt  in 
the  neck,  passing  from  beneath  the  posterior 
border  of  the  sterno-mastoid  to  enter  the  axilla 
just  externally  to  the  mid-point  of  the  clavicle. 
The  upper  trunk,  formed  by  the  fifth  and  sixth 
nerves,  is  by  far  the  most  exposed  to  injury,  for 
the  reason  that  it  rises  higher  in  the  neck  than  the 
middle  and  lower  trunks ;  hence  when  the  neck  is 
bent  forcibly  to  the  left,  as  when  a  burden  is 
borne  on  the  right  shoulder,  the  upper  trunk  on 
the  right  side  is  subjected  to  a  greater  strain  than 
the  middle  or  lower  cords.     In  cases  of  shoulder- 


Chap.  XI]     REGION    OF    THE    SHOULDER 


239 


presentation  at  birth,  or  if  the  neck  and  shoulder 
be  forced  apart  by  accident,  the  upper  cord  is  lia- 
ble to  be  strained  or  ruptured,  resulting  in  what  is 
usually  described  as  Erb's  palsy.  _  It  will  be  re- 
called that  the  suprascapular,  circumflex,  and 
musculo-cutaneous  nerves  are  derived  from  this 
trunk;   so   are   the   nerves  to  the   rhomboids   and 


UPRASPINATUS 


SCAPU 


ACROMIO/i    Proc 

Deltoid 
Capsule 
Bursa 

Epiphyseal  Line:'. 

JoirtT  Cavity 

CjLEttOlD    LlQAME/^T 

—4-  Capsule 

P05t.Cir.cu/mflex  Art 

4_TeR.ES   /iAJOR 

Triceps 


W 

Fig.  40. — Section  of  the  shoulder-joint  to  show  the   relations    of    the 
capsule,  epiphyseal  line,  and  bursa.    (After  Poirier.) 

serratus  magnus.  The  rupture,  however,  is  usually 
distal  to  the  origin  of  these  nerves,  and  hence 
their  muscles  escape.  The  muscles  affected  in 
Erb's  palsy  are  the  supraspinatus,  infraspina- 
tus, teres  minor,  deltoid,  coraco-brachialis,  biceps, 
brachialis  anticus,  and  supinator  longus;  occa- 
sionally also  the  supinator  brevis,  extensor  carpi 
radialis  longior.,  and  pronator  radii  teres.  No 
sensory  paralysis  is  observed  in  such  cases.  Curi- 
ously enough,  section  of  the  fifth  cervical  gives 
as  wide  an  area  of  muscular  paralysis  as  section 


240  SURGICAL    APPLIED    ANATOMY   [Part  III 

of  the  combined  fifth  and  sixth  (W.  Harris).  In 
complete  rupture  of  the  brachial  plexus  sensation 
is  completely  lost  beyond  the  elbow,  but  in  the  arm 
and  shoulder  deep  sensibility  is  retained  (Sher- 
ren).  The  arm,  in  such  lesions,  retains  intact  the 
nerves  received  from  the  descending  cervical  and 
intercosto-humeral. 

The  axillary  nerves. — Any  of  the  axillary 
nerves  may  be  injured  by  a  wound,  the  median 
being  the  most  frequently  damaged,  and  the  mus- 
culo-spiral  the  least  frequently.  The  comparative 
immunity  of  the  latter  is  explained  by  its  deep 
position,  its  situation  at  the  inner  and  posterior 
aspect  of  the  limb,  and  its  large  size.  The  nerves 
are  very  seldom  torn  by  a  traction  on  the  limb 
short  of  more  or  less  complete  avulsion.  Indeed, 
if  forcibly  stretched,  they  are  disposed  rather  to 
become  torn  away  from  their  attachments  to  the 
spinal  cord  than  to  give  way  in  the  axilla.  Thus, 
Flaubert  records  a  case  where  the  last  four  cervi- 
cal nerves  were  torn  away  from  the  cord  during 
a  violent  attempt  to  reduce  a  dislocated  shoulder. 

The  deltoid  region. — This  region,  comprising 
as  it  does  the  "  point  "  of  the  shoulder,  is  limited 
in  all  parts  by  the  deltoid  muscle.  The  deltoid 
covers  the  upper  end  of  the  humerus  and  the 
shoulder-joint  (Fig.  40).  Between  the  joint  and 
the  surface,  therefore,  are  only  the  skin  and  super- 
ficial fascia,  the  deltoid  in  its  sheath,  and  some 
loose  connective  tissue  (the  subdeltoid  tissue)  in 
which  is  found  the  great  subacromial  bursa.  This 
subdeltoid  tissue  sometimes  assumes  the  form  of  a 
distinct  thick  membrane,  and  may  have  an  im- 
portant influence  upon  the  localisation  of  puru- 
lent collections  proceeding  from  the  joint.  The 
fatty  tissue  over  the  deltoid  is  a  favourite  seat 
for  lipomata,  and  it  is  in  this  situation  that  the 
tendency  of  these  growths  to  change  their  position 
is  sometimes  seen.  Thus,  Erichsen  records  a  case 
where  the  tumour  slid  downwards  from  the 
shoulder  to  the  breast. 

Emerging  from   the  interval   between   the  two 


Chap.  XI]     REGION    OF    THE    SHOULDER  241 

teres  muscles,  and  winding  horizontally  round  the 
shaft  of  the  humerus,  quite  close  to  the  bone,  and 
about  the  line  of  the  surgical  neck,  are  the  circum- 
flex nerve  and  posterior  circumflex  artery.  This 
nerve  affords  an  example  of  an  arrangement 
pointed  out  by  Mr.  Hilton,  viz.  that  a  principal 
nerve  to  a  joint  not  only  supplies  the  articular 
surfaces,  but  also  some  of  the  main  muscles  that 
move  that  joint,  and  the  skin  over  those  muscles. 
This  nerve  supplies  the  shoulder-joint,  the  deltoid 
and  teres  minor  muscles,  and  the  skin  over  the 
lower  two-thirds  of  the  shoulder  and  upper  part 
of  the  triceps.  This  nerve  is  frequently  damaged 
in  injuries  to  the  shoulder.  It  may  be  severely 
bruised  by  a  simple  contusion  of  the  part,  and 
this  bruising  may  be  followed  by  paralysis  of  the 
deltoid.  It  would  appear,  however,  that  damage 
to  the  circumflex  is  much  less  frequent  after  con- 
tusions of  the  shoulder  than  was  formerly  main- 
tained. It  will  also  be  readily  understood  that 
the  nerve  is  often  torn  in  fractures  of  the  surgical 
neck  of  the  humerus,  in  dislocations  of  that  bone 
(especially  the  luxation  backwards),  and  in  vio- 
lent attempts  at  reducing  such  dislocations.  The 
nerve,  from  its  position,  is  very  apt  to  be  seri- 
ously pressed  upon  by  growths  springing  from  the 
upper  end  of  the  humerus. 

The  shoulder-joint.— From  one  surgical  point 
of  view,  joints  may  be  divided  into  (1)  those  that 
depend  for  their  strength  mainly  upon  ligaments ; 
(2)  those  that  are  mechanically  strong,  and  that 
derive  their  stability  to  a  great  extent  from  the 
arrangement  of  their  component  bones;  and  (3) 
those  that  rely  for  their  support  principally  upon 
muscles.  As  an  example  of  the  first  kind  may  be 
cited  the  sterno-clavicular  joint,  of  the  second 
form  the  elbow-joint,  and  of  the  third  the 
shoulder-joint.  The  articulation  the  least  prone 
to  dislocation  is  the  one  that  derives  its  strength 
from  tough  unyielding  ligaments,  while  the  one 
most  often  luxated  belongs  to  the  third  variety,  its 
strength  being  greatly  dependent  upon  muscles 
Q 


242  SURGICAL    APPLIED    ANATOMY       [Part  III 

that  may  be  taken  by  surprise,  and  that  may  them- 
selves, from  disordered  action,  prove  sources  of 
weakness.  These  are,  of  course,  not  the  only  fea- 
tures in  the  etiology  of  dislocation.  A  great  deal 
depends  upon  the  amount  of  movement  permitted 
in  a  given  joint,  and  the  degree  of  leverage  that 
can  be  brought  to  bear  upon  its  parts. 

The  arch  formed  by  the  coracoid  and  acromion 
processes  and  the  ligament  between  them  forms  an 
essential  support  to  the  head  of  the  humerus,  and 
is  an  important  constituent  of  the  articulation. 
With  this  arch  the  humeral  head  is  in  immediate 
relation,  though  not  in  actual  contact  (Fig.  40). 
In  paralysis  of  the  deltoid  the  head  may  be 
separated  by  some  distance  from  the  coracoid 
process,  and  Nannoni  records  the  case  of  a  child 
with  old-standing  paralysis  of  the  deltoid,  between 
whose  humeral  head  and  acromial  vault  four  fin- 
gers could  be  lodged.  It  is  well  to  note  that  at 
least  two-thirds  of  the  head  of  the  bone  are  not 
in  contact  with  the  glenoid  cavity  when  the  arm 
hangs  by  the  side,  and  Anger  points  out  that  in 
this  position  three-fourths  of  the  circumference 
of  the  humeral  head  are  in  front  of  a  vertical  line 
drawn  from  the  anterior  border  of  the  acromion 
process.  In  this  posture,  also,  the  head  is  wholly 
to  the  outer  side  of  the  coracoid  process.  The 
margin  of  the  glenoid  cavity  is  more  prominent 
on  the  inner  than  on  the  outer  side,  while  the 
strongest  part  of  the  margin  and  the  broadest 
part  of  the  fossa  are  below.  This  is  significant, 
since  it  points  to  an  attempt  to  strengthen  a  part 
of  the  joint  that  practice  shows  to  be  the  weakest 
in  the  articulation,  viz.  the  lower  and  inner  por- 
tion of  the  capsule.  It  is  at  this  place  that  the 
head  of  the  bone  leaves  the  joint  in  dislocation  of 
the  shoulder. 

The  capsule  of  the  shoulder- joint  is  very  lax, 
and  would  lodge  a  bone-head  twice  as  large  as  that 
of  the  humerus.  According  to  Henry  Morris,  no 
one  part  of  the  capsule  is  constantly  thicker  than 
the  rest,  as  is  the  case  in  the  hip- joint. 


Chap.  XI]     EEGION    OF    THE    SHOULDER  243 

Of  the  nursse  about  the  joint,  the  subacromial 
bursa  is  the  one  most  frequently  the  seat  of  disease. 
This  sac,  when  distended  with  fluid,  may  be  mis- 
taken for  the  results  of  chronic  inflammation  of 
the  joint  (Fig.  40). 

Experiment  shows  that  the  walls  of  this  bursa 
may  be  actually  torn  in  twists  of  the  arm,  especi- 
ally when  either  flexed  or  extended  (Nancrede). 
When  the  sac  is  distended  most  pain  is  elicited  in 
the  position  of  abduction,  for  in  this  posture  the 
bursal  walls  are  normally  folded  up,  so  as  to  form 
a  sort  of  collar  in  advance  of  the  greater  tuber- 
osity. When  the  walls  are  thickened  and  dis- 
tended by  inflammation,  abduction  mustf  press 
the  bursa  very  forcibly  under  the  acromion,  and 
so  cause  pain.  In  elderly  rheumatic  people  the 
sac  sometimes  communicates  with  the  joint.  The 
subscapular  bursa  may  be  regarded  as  an  exten- 
sion of  the  synovial  membrane  of  the  joint  between 
the  terminal  part  of  the  muscle  and  the  scapula. 
Pain  elicited  when  the  arm  is  rotated  at  the 
shoulder- joint  may  be  due  to  disease  in  the  joint, 
in  the  subacromial  or  in  the  subscapular  bursa, 
for  a  movement  then  occurs  in  all  three. 

The  biceps  tendon  strengthens  the  upper 
part  of  the  joint,  keeps  the  humerus  against  the 
glenoid  cavity  in  the  various  positions  of  the  limb, 
and  prevents  the  head  of  the  bone  from  being 
pulled  too  closely  upwards  under  the  acromion. 
The  tendon  may  be  ruptured,  and  in  such  a  case, 
in  addition  to  the  general  weakening  of  the  limb, 
and  the  peculiar  projection  formed  by  the  con- 
traction of  the  muscle,  the  head  of  the  humerus  is 
usually  drawn  upwards  and  forwards  until  ar- 
rested by  the  coraco-acromial  arch.  Thus,  a  kind 
of  slight  false  dislocation  may  be  produced.  In 
certain  violent  wrenches  of  the  limb  the  tendon 
may  slip  from  its  groove  and  be  displaced  to  one 
or  other  side,  usually  to  the  inner  side.  In  these 
cases  also  the  head  is  drawn  up  under  the 
acromion,  and  is  prominent  in  front,  while  abduc- 
tion is  rendered  less  free  than  is  normal  owing  to 


244  SURGICAL    APPLIED    ANATOMY      [Part  III 

the  great  tuberosity  being  sooner  brought  in  con- 
tact with  the  acromion.  The  intracapsular  part 
of  the  tendon  may  disappear  in  cases  of  chronic 
rheumatic  arthritis,  owing  to  the  friction  against 
the  abraded  articular  surface  of  the  humerus.  It 
acquires  an  attachment  to  the  bicipital  groove  in 
such  cases. 

Joint  disease. — This  articulation  is  liable  to 
all  forms  of  joint  disease.  The  capsule,  as  just 
stated,  is  very  lax,  the  articular  surfaces  being 
kept  in  apposition  by  the  tonus  of  the  surrounding 
muscles ;  when  chloroform  is  administered  the  sur- 
faces may  be  freely  separated  and  examined.  In 
joint  disease,  however,  the  effusion  may  effect  a 
considerable  separation  of  the  two  bones.  Braune, 
having  pierced  the  glenoid  cavity  through  the 
supraspinous  fossa,  injected  tallow  at  considerable 
pressure  into  the  joint.  When  fully  distended 
the  humerus  was  found  to  be  separated  from  the 
scapula  by  more  than  ^  an  inch,  and  this  may 
serve  to  explain  the  lengthening  of  the  limb  often 
noted  in  joint  disease  of  this  part  with  much 
effusion.  When  the  greatest  degree  of  distension 
of  the  capsule  was  reached  the  humerus  became 
slightly  extended  and  rotated  inwards.  It  is 
significant  that  in  shoulder-joint  disease  it  is  com- 
mon for  the  arm  to  be  found  close  to  the  side,  the 
elbow  carried  a  little  back  (extension),  and  the 
limb  rotated  inwards.  This  position  may  also  be 
due  to  the  rigid  contraction  of  the  muscles  about 
the  joint  that  is  usually  observed.  When  such 
contractions  exist  it  may  be  inferred  that  the 
powerful  latissimus  dorsi  has  a  little  advantage 
over  its  opponents,  and  may  be  answerable  for  the 
rotation  in  and  slight  projection  backwards  of  the 
arm.  The  inner  part  of  the  epiphyseal  cartilage 
is  just  within  the  capsule ;  the  outer,  anterior,  and 
posterior  parts  are  entirely  subperiosteal.  It 
happens,  therefore,  that  the  pus  in  suppurative 
epiphysitis  will  find  its  way  into  the  joint. 

There  are  two  diverticula  from  the  synovial 
membrane  :  (1)  one  that  runs  some  way  down  the 


Chap.  XI]     REGION    OF    THE    SHOULDER  245 

bicipital  groove  with  the  tendon ;  (2)  a  cul-de-sac 
beneath  the  subscapulars  formed  by  a  communica- 
tion between  the  synovial  cavity  and  the  bursa 
under  that  muscle.  When  the  joint  is  filled  with 
effusion,  the  capsule  is  evenly  distended  and  the 
shoulder  evenly  rounded.  Special  projections 
usually  occur  at  the  seats  of  the  diverticula.  Thus 
a  swelling  often  appears  early  in  the  course  of  a 
synovitis  in  the  groove  between  the  pectoralis 
major  and  the  deltoid  muscles,  and  this  swelling 
may  appear  bilobed,  being  cut  in  two  by  the  un- 
yielding biceps  tendon  (Paulet).  Fluctuation 
can  best  be  felt  by  examining  the  uncovered  part 
of  the  capsule  in  the  axilla  beyond  the  subscapu- 
lar muscle.  When  the  joint  suppurates  pus 
usually  escapes  at  one  of  the  culs-de-sac  just 
mentioned,  most  often  through  the  one  that  fol- 
lows the  biceps  tendon.  Pus  may  thus  extend  for 
some  way  along  the  bicipital  groove.  Pus  escap- 
ing through  the  subscapular  cul-de-sac  is  apt  to 
spread  between  the  muscle  and  the  venter  of  the 
scapula,  and  to  present  at  the  lower  and  back  part 
of  the  axilla.  Purulent  collections  beneath  the 
deltoid  are  nearly  always  conducted  towards  the 
anterior  aspect  of  the  limb,  being  unable  to  pro- 
ceed backwards  owing  to  the  denseness  of  the 
fascia  covering  in  the  deltoid  and  infraspinous 
muscle.  In  one  recorded  case,  pus  that  had 
escaped  from  the  shoulder-joint  followed  the 
course  of  the  musculo-spiral  nerve,  and  opened  on 
the  outer  side  of  the  elbow.  _ 

Dislocations. — Dislocations  at  this  joint  are 
more  common  than  at  any  other  joint  in  the  body. 
This  is  explained  by  the  shallowness  of  the  glenoid 
fossa,  the  large  size  and  globular  shape  of  the  head 
of  the  humerus,  the  extensive  movements  of  the 
arm,  the  long  leverage  it  affords,  and  the  depend- 
ence of  the  articulation  for  its  strength  mainly 
upon  muscles.  The  upper  limb  and  shoulder  are 
also  peculiarly  exposed  to  injury. 

The  principal  forms  of  luxation  of  the  humerus 
at  the  shoulder  are  :  1.  Subcoracoid,  forwards  and 


246  SURGICAL    APPLIED    ANATOMY      [Part  III 

a  little  downwards ;  the  usual  form.  2.  Sub- 
glenoid, downwards  and  a  little  forwards;  rare. 
3.  Subspinous,  backwards ;  rare. 

In  all  complete  dislocations  the  head  of  the 
bone  leaves  the  joint  cavity  through  a  rent  in  the 
capsule.  In  so-called  "  false  luxations  ,;  the  cap- 
sule is  not  torn.  For  example,  in  the  cadaver, 
if  the  deltoid  be  divided  the  humeral  head  can  be 
displaced  under  the  coracoid  process  without  rup- 
ture of  the  capsule,  and  the  same  thing  may  occur 
during  life,  in  cases  where  the  muscle  has  long 
been  paralysed. 

In  all  cases  of  dislocation  at  this  joint  the 
primary  displacement  is  always  downwards  into 
the  axilla.  It  is  well  known  that  dislocations  at 
the  shoulder  are  usually  due  to  violence  applied 
to  the  limb  while  the  arm  is  abducted,  or  to  severe 
direct  violence  forcing  the  bone  downwards.  Now 
when  the  limb  is  abducted  the  head  of  the  humerus 
projects  below  the  glenoid  fossa,  and  rests  and 
presses  upon  the  inferior  and  least  protected  part 
of  the  capsule.  The  fibres  of  this  portion  of  the 
capsule  being  tightly  stretched  in  this  position, 
it  requires  no  extraordinary  force  to  tear  the 
ligament  and  drive  the  bone  into  the  axilla. 

Thus  it  happens  that  in  luxations  at  this  joint 
the  rent  in  the  capsule  is  at  its  inferior  and  inner 
aspect,  the  humeral  head  lying  beneath  the  sub- 
scapulars, which  is  always  strained  and  some- 
times torn.  The  head  of  the  bone,  being  thus 
driven  downwards  into  the  axilla,  may,  for  cer- 
tain reasons,  remain  there  (subglenoid  form),  or 
more  usually  it  will  be  drawn  forwards  and  in- 
wards by  the  powerful  pectoralis  major,  aided 
by  other  muscles  whose  action  is  now  less  resisted 
and  by  the  weight  of  the  unsupported  limb  (sub- 
coracoid  form) ;  and  lastly,  the  direction  of  the 
violence  being  applied  markedly  from  in  front, 
the  head  of  the  bone  may  be  thrust  backwards 
under  the  acromion  or  spinous  processes  (sub- 
spinous form).  The  overwhelming  frequency  of 
the  subcoracoid  variety  is  explained  by  the  greater 


Chap.  XI]       REGION    OF    THE    SHOULDER  247 

advantage  at  which  those  muscles  act  that  draw 
the  bone  forwards,  in  comparison  with  those  that 
would  draw  it  backwards,  and  by  the  very  trifling 
opposition  offered  to  the  passage  of  the  head  for- 
wards when  compared  with  the  substantial  ob- 
stacles in  the  way  of  its  passage  backwards  under 
the  scapular  spine. 

Features  eommoit  to  all  dislocations  at 
tlie  shoulder.  —  As  the  roundness  of  the  deltoid 
depends  to  a  great  extent  upon  the  presence  be- 
neath it  of  the  humeral  head,  and  as  in  all  these 
luxations  (save  perhaps  in  the  slighter  grades  of 
the  subspinous  form)  the  head  is  removed  practi- 
cally from  its  connection  with  the  deltoid,  that 
muscle  is  always  more  or  less  flattened.  This 
flattening  is  augmented  by  the  _  stretching  of  the 
muscle,  which  in  some  degree  is  constantly  pre- 
sent. Stretching  of  the  deltoid  involves  abduc- 
tion of  the  arm,  and  this  symptom  is  fairly  con- 
stant in  all  the  luxations.  The  biceps  being  also 
more  or  less  unduly  tense,  the  elbow  is  found 
flexed  and  the  forearm  supinated.  In  every  form 
there  is  some  increase  in  the  vertical  circumfer- 
ence of  the  axilla,  since  the  head,  having  left  the 
glenoid  fossa,  must  occupy  some  part  comprised 
within  that  circumference.  Again,  Dr.  Dugas 
has  pointed  out  that  "  if  the  fingers  of  the  in- 
jured limb  can  be  placed  by  the  patient,  or  by  the 
surgeon,  upon  the  sound  shoulder  while  the  elbow 
touches  the  thorax  (a  condition  that  obtains  in 
the  normal  condition  of  the  joint),  there  can  be 
no  dislocation ;  and  if  this  cannot  be  done  there 
must  be  one,  for  no  injury  other  than  a  disloca- 
tion can  induce  this  physical  impossibility."  This 
depends  upon  the  fact  that  in  consequence  of  the 
rotundity  of  the  thorax  it  is  impossible  for  both 
ends  of  the  humerus  to  touch  it  at  the  same  time, 
and  in  luxation  at  the  shoulder  the  upper  end  of 
the  bone  is  practically  touching  the  trunk.  Lastly, 
from  the  position  of  the  great  vessels  and  nerves 
it  will  be  seen  that  in  the  subcoracoid  and  sub- 
glenoid luxations  the  head  of  the  bone  may  press 


248 


SURGICAL    APPLIED    ANATOMY      [Part  III 


injuriously  upon  those  structures.  Thus  may 
result  oedema  of  the  limb  and  severe  pain  or  loss  of 
muscular  power.  The  artery  is  usually  saved  by 
its  greater  elasticity ;  but  Berard  reports  a  case 
of  displacement  forwards  where  the  axillary 
artery  was  so  compressed  by  the  humeral  head 
as  to  induce  gangrene  of  the  limb. 

The  close  connection  of  the  circumflex  nerve 
with  the  humerus  renders  it  very  liable  to  injury, 
especially  in  the  subglenoid  and  subspinous  forms 
of  dislocation. 

Special  anatomy  of  each  form. — 1.  Sub- 
coracoid.  The  articular  head  of  the  humerus  lies 
on  the  anterior  surface  of  the  neck  of  the  scapula, 
and  the  anatomical  neck  rests  on  the  anterior  lip 
of  the  glenoid  fossa.  The  head  is  thus  placed 
immediately  below  the  coracoid  process,  and  is 
in  front  of,  internal  to,  and  a  little  below,  its 
normal  site.  The  great  tuberosity  faces  the  empty 
glenoid  cavity  (Fig.  41).  The  subscapulars  mus- 
cle is  stretched 
over  the  head  of 
the  humerus,  and 
is  usually  in  some 
part  torn.  The 
s  u  p  r  aspinatus, 
inf  rasp  inatus, 
and  teres  minor 
are  stretched  or 
torn,  or  the  great 
tuberosity  may 
even  be  wrenched 
off.  The  coraco- 
brachialis  and 
short  head  of  the 
biceps  are  tense, 
and  are  immedi- 
ately in  front  of 
the  head  of  the 
humerus  instead  of 
to  its  inner  side.  The 

41. — Subeoracoia    cusloration    of   the     ,  ,  „     , 

lmmerus.  long  tendon  or  the 


Pig. 


Chap.  XI]     REGION    OF    THE    SHOULDER  249 

biceps  is  deflected  downwards  and  outwards.  It  is 
sometimes,  although  rarely,  torn  from  its  groove. 
The  deltoid  is  put  upon  the  stretch.  The  pro- 
minence formed  by  the  humeral  head  in  the  front 
of  the  axilla  depends  to  some  degree  upon  the 
amount  of  rotation.  If  the  bone  be  rotated  out, 
the  projection  is  most  distinct;  but  if  rotated  in, 
its  head  sinks  into  the  axilla  and  is  brought  more 
in  contact  with  the  scapula  than  with  the  skin. 
The  head  of  the  bone  being  always  carried  a  little 
downwards,  some  lengthening  must  in  all  cases 
really  exist;  but  with  the  ordinary  method  of 
measuring  the  limb  this  lengthening  may  be  re- 
placed by  a  normal  measurement,  or  even  by 
apparent  shortening,  if  the  head  of  the  bone  be 
carried  a  good  deal  forwards  and  inwards,  and 
the  limb  be  abducted.  When  the  head  has  left 
the  glenoid  cavit}^,  abduction  tends  to  bring  the 
external  condyle  nearer  to  the  acromion,  and  these 
are  the  two  points  between  which  the  measurement 
is  usually  taken.  Thus  the  apparent  length  of 
the  arm  depends  mainly  upon  the  degree  of  abduc- 
tion of  the  humerus,  or  the  obliquity  of  the  axis 
of  the  bone. 

2.  Subglenoid. — The  head  is  below,  and  a  little 
in  front  of  and  internal  to,  its  normal  position. 
It  cannot  go  directly  downwards,  owing  to  the 
situation  of  the  long  head  of  the  triceps,  but 
escapes  in  the  interval  between  that  muscle  and 
the  subscapularis.  The  articular  head  rests  on 
the  anterior  aspect  of  the  triangular  surface  just 
below  the  glenoid  fossa  that  gives  origin  to  the 
triceps.  The  upper  border  of  the  great  tuberosity 
is  in  close  relation  with  the  lower  margin  of  the 
joint.  It  is  generally  stated,  on  the  authority 
of  Malle,  that  the  circumstance  which  prevents 
the  head  of  the  bone  from  being  drawn  upwards 
is  the  entirety  of  the  anterior  part  of  the  capsule, 
the  rent  being  in  the  lower  part  only  of  that  liga- 
ment. The  subscapularis  muscle  is  much  stretched 
or  torn,  and  the  head  usually  lies  beneath  its  ten- 
don, and  upon  some  fibres  of  the  disturbed  muscle. 


250 


SURGICAL    APPLIED    ANATOMY      [Part  III 


The  supraspinatus  will  be  torn.  The  infraspina- 
tus will  be  stretched  or  torn,  and  the  two  teres 
muscles  will  not  be  much  affected  unless  there  be 
considerable  abduction  of  the  arm.  The  coraco- 
brachialis  and  biceps  will  be  stretched,  but  owing 
to  the  amount  of  abduction  usually  present  the 
biceps  tendon  is  but  little  deflected  from  a  straight 
line.  The  deltoid  is  greatly  stretched,  and  its  ten- 
sion serves  to  produce  the  extreme  flattening  of  the 
shoulder  and  the  great  abduction  common  in  this 
injury.  Some  lengthening  is  seldom  absent,  al- 
though it  is  always  modified  by  the  abduction  that 
exists. 

3.  Subspinous.  —  The  head  usually  rests  on 
the  posterior  surface  of  the  neck  of  the  scapula, 
the  groove  of  the  anatomical  neck  of  the  humerus 
corresponding  to  the  posterior  lip  of  the  glenoid 
fossa.  The  head  is  thus  placed  beneath  the 
acromion ;  but  it  may  be  displaced  still  farther 
back,  and  may  rest  on  the  dorsum  scapulae,  and 
beneath  the  scapular  spine  (Fig.  42).  The  sub- 
scapulars   tendon     is    drawn    right    across    the 

glenoid  fossa,  and  is 
often  torn  from  its 
attachment.  The  head 
pushes  back  the  hinder 
part  of  the  deltoid, 
the  infraspinatus  and 
teres  minor  muscles. 
These  latter  cover  the 
bone,  and  are  stretched 
over  it.  The  supra- 
spinatus is  tense,  asis 
also  the  biceps,  while 
the  teres  major  and 
latissimus  dorsi  are 
relaxed.  The  great 
pectoral  is  rendered 
unduly  tense,  and  this 
serves   in   part   to   ex- 

-subspinous  dislocation  of     Plai?  the  rotation  in- 
the  humerus.  wards  oi  the  humerus, 


Chap.  XI]     EEGION    OF    THE    SHOULDEE  251 

and  the  abduction  forwards,  that  are  usually  ob- 
served, those  movements  being  more  or  less  unop- 
posed.    The  circumflex  nerve  is  often  torn. 

In  reducing  dislocations,  especially  such  as  are 
of  long  standing,  serious  damage  may  be  inflicted 
on  the  axillary  structures.  The  axillary  artery 
suffers  most  frequently,  the  vein  rarely,  and  the 
nerves  still  less  often.  The  artery,  being  placed 
externally,  is  apt  to  contract  adhesions  to  the 
soft  parts  covering  the  head  of  the  displaced  bone, 
and  to  be,  therefore,  torn  when  those  parts  are 
disturbed. 

Fractures  of  the  upper  end  of  the 
humerus. — 1.  Anatomical  neck.  The  upper 
part  of  the  capsule  is  exactly  attached  to  the  ana- 
tomical neck,  and  in  this  situation  the  fracture 
may  run  beyond  the  ligament  and  be  partly  extra- 
capsular (Fig.  40,  p.  239).  The  lower  part  of  the 
capsule  is  inserted  some  little  wTay  below  the  ana- 
tomical neck,  and  in  this  position,  therefore,  the 
lesion  must  be  intracapsular.  From  the  line  of 
attachment  of  the  lower  part  of  the  capsule  to 
the  humerus,  fibres  are  reflected  upwards  to  the 
margin  of  the  articular  cartilage  on  the  head  of 
the  bone.  These  fibres,  if  unruptured,  may  serve 
to  connect  the  fragments.  If  entirely  separated, 
the  head  of  the  bone  must  necrose,  having  no  such 
source  of  blood  supply  as  the  head  of  the  femur 
derives  from  the  round  ligament.  It  is  easy  for 
the  small  and  comparatively  dense  upper  frag- 
ment to  be  driven  into  the  wide  surface  of  can- 
cellous bone  exposed  on  the  upper  surface  of  the 
lower  fragment.  When  impaction  occurs,  there 
may  be  some  flattening  of  the  deltoid,  since  the 
head  is  rendered  of  less  dimensions  by  that  im- 
paction, and  consequently  causes  a  less  projection 
of  the  deltoid.  It  may  be  possible  to  detect  the 
impaction  by  examination  through  the  axilla  when 
the  arm  is  fully  abducted.  The  difficulty  of  ob- 
taining crepitus  in  non-impacted  fractures  will 
be  obvious  when  the  small  size  of  the  upper  frag- 
ment    is     considered,     together     with     its     great 


252  SUEGICAL    APPLIED    ANATOMY      [Part  III 

mobility,  and  the  obstacles  in  the  way  of  so  fixing 
it  that  one  broken  end  may  be  rubbed  against  the 
other. 

The  amount  of  displacement  is  to  be  measured 
by  the  laxity  of  the  capsule.  The  usual  deviation 
is  a  projection  of  the  upper  end  of  the  lower 
fragment  towards  the  anterior  and  inner  side  of 
the  articulation,  brought  about  mainly  by  the 
muscles  attached  to  the  bicipital  groove.  In  no 
case  could  the  two  bone-ends  overlap. 

2.  Separation  of  the  upper  epiphysis. — The 
lower  border  of  this  epiphysis  is  represented  by  a 
line  crossing  the  bone  at  the  base  of  the  great 
tuberosity  and  placed  between  the  anatomical 
and  surgical  necks  (see  Fig.  40,  p.  239).  It  would 
be  fairly  indicated  by  a  transverse  saw-cut 
through  the  widest  part  of  the  bone.  The  three 
component  nuclei  of  this  epiphysis  (head,  greater 
and  lesser  tuberosities)  fuse  together  about  the 
fifth  year,  and  the  entire  mass  joins  the  shaft 
about  the  twentieth  year.  The  upper  fragment 
may  be  carried  and  rotated  a  little  outwards  by 
the  muscles  attached  to  the  great  tuberosity,  while 
the  lower  fragment  is  drawn  inwards  and  for- 
wards by  the  muscles  inserted  into  the  bicipital 
groove.  Thus,  a  part  of  the  smooth  upper  erid  of 
the  lower  fragment  commonly  forms  a  distinct 
projection  below  the  coracoid  process.  In  such 
case  the  axis  of  the  limb  would  be  altered,  and 
the  elbow  carried  a  little  from  the  side.  Often, 
however,  the  displacement  is  solely  in  the  antero- 
posterior direction,  the  lower  fragment  project- 
ing forwards.  So  wide  are  the  two  bone  surfaces 
at  the  seat  of  injury  that  it  is  scarcely  possible 
for  them  to  overlap  one  another. 

3.  Surgical  neck. — The  surgical  neck  is  situ- 
ated between  the  bases  of  the  tuberosities  and  the 
insertions  of  the  latissimus  dorsi  and  teres  major 
muscles.  A  common  displacement  of  parts  is  the 
following.  The  upper  fragment  is  carried  out 
and  rotated  out  by  the  supra-  and  infraspinatus 
and   teres   minor.     The   upper   end   of   the   lower 


Chap.  XI]     REGION    OF    THE    SHOULDER  253 

fragment  is  drawn  upwards  by  the  deltoid,  biceps, 
coraco-brachialis,  and  triceps,  inwards  by  the 
muscles  attached  to  the  bicipital  groove,  and  for- 
wards by  the  great  pectoral.  Thus  it  forms  a 
projection  in  the  axilla,  and  the  axis  of  the  limb 
*  is  altered  so  that  the  elbow  projects  from  the  side. 
This  displacement,  however,  is  by  no  means  con- 
stant. Pean,  Anger,  and  others  maintain  that  the 
usual  deformity  is  a  projection  of  the  upper  end 
of  the  lower  fragment  forwards,  and  that  this 
deviation  is  due  to  the  nature  and  direction  of 
the  violence,  and  not  to  muscular  action.  In  some 
cases  there  is  no  displacement,  the  broken  ends 
being  retained  in  situ,  probably,  by  the  biceps 
tendon  and  the  long  head  of  the  triceps.  In  at 
least  one  instance  (Jarjavay)  the  lower  fragment 
was  so  drawn  upwards  and  outwards,  apparently 
by  the  deltoid,  as  to  nearly  pierce  the  skin  of  the 
shoulder.  Hamilton  comes  to  the  general  con- 
clusion "  that  complete  or  sensible  displacement 
is  less  common  at  this  fracture  than  in  most  other 
fractures,"  and  in  this  conclusion  many  surgeons 
agree. 

Amputation  at  the  shoulder  joint. — "  Flap 
method  " :  "  deltoid  flap  "  (Fig.  43).  In  the 
outer  flap  are  only  the  deltoid  and  a  few  small 
vessels  derived  from  the  acromio-thoracic  and  the 
two  circumflex  arteries.  The  cephalic  vein  and 
descending^  branch  of  the  acromio-thoracic  artery 
are  in  the  inner  flap.  The  anterior  and  posterior 
borders  of  the  inner  flap  show  portions  of  the 
deltoid  muscle.  Along  its  lower  border  from  be- 
fore backwards  are  sections  of  the  pectoralis 
major,  the  short  head  of  the  biceps  and  coraco- 
brachialis,  the  axillary  vessels  and  nerves,  the 
latissimus  dorsi  and  teres  major,  the  triceps,  and 
the  posterior  portion  of  the  deltoid.  The  trunks 
of  the  posterior  circumflex  artery  and  nerve  are 
found  divided  on  the  posterior  part  of  the  surface 
of  the  flap,  between  the  sections  of  the  triceps 
and  deltoid,  and  not  far  from  the  angle  between 
the  two  flaps. 


254 


SURGICAL    APPLIED    ANATOMY       [Part  III 


Oval  method  (Spence).  The  parts  cut  and  the 
order  of  their  division  are  practically  the  same  as 
obtain  in  the  anterior  and  inferior  borders  of  the 
two  flaps  made  in  the  previous  method.  The  an- 
terior incision,  being  a  little  more  vertical  than 


Fig.  43. — Amputation  at  shoulder-joint:  flap-method.    (Agatz.) 

a,  Glenoid  cavity  ;  It,  deltoid ;  c,  long  head  of  biceps ;  d,  pectoralis  major ;  e,  biceps 
and  coraco-brachialis  ;  /;  latissimus  dorsi  and  teres  major ;  g,  triceps  ;  1,  axillary 
vessels  ;  2,  circumflex  vessels ;  3,  brachial  plexus. 

is  the  gap  between  the  two  flaps,  divides  more  of 
the  pectoralis  major  and  cuts  the  cephalic  vein 
higher  up.  The  posterior  circumflex  vessels  and 
nerve  are  separated  from  the  bone  by  the  finger 
and  are  retained,  one  advantage  of  the  procedure 
being  that  only  a  few  of  the  terminal  branches 
of  that  artery  are  divided. 


CHAPTER    XII 

THE   ARM 

The  arm,  upper  arm,  or  brachial  region  is  con- 
sidered to  extend  from  the  axilla  above  to  the 
region  of  the  elbow  below. 

Surface  anatomy.— In  women,  and  in  those 
who  are  fat,  the  outline  of  the  arm  is  rounded 
and  fairly  regular.  It  is  less  regular  in  the  mus- 
cular, in  whom  it  may  be  represented  by  a 
cylinder,  somewhat  flattened  on  either  side  and 
unduly  prominent  in  front  (biceps  muscle).  The 
outline  of  the  biceps  muscle  is  distinct,  and  on 
either  side  of  it  is  a  groove.  The  inner  of  the 
two  grooves  is  by  far  the  more  conspicuous.  It 
runs  from  the  bend  of  the  elbow  to  the  axilla,  and 
indicates  generally  the  position  of  the  basilic  vein 
and  brachial  artery.  The  outer  groove  is  shal- 
low, and  ends  above  at  the  insertion  of  the  deltoid 
muscle.  So  far  as  it  goes  it  marks  the  position 
of  the  cephalic  vein. 

The  insertion  of  the  deltoid  can  be  well  made 
out,  and  is  an  important  landmark.  It  indicates 
very  precisely  the  middle  of  the  shaft  of  the 
humerus,  is  on  the  same  level  with  the  insertion 
of  the  coraco-brachialis  muscle,  and  marks  the 
upper  limit  of  the  brachialis  anticus.  It  corre- 
sponds also  to  the  spot  where  the  cylindrical 
part  of  the  humeral  shaft  joins  the  prismatic 
portion,  to  the  point  of  entrance  of  the  nutrient 
artery,  and  to  the  level  at  which  the  musculo- 
spiral  nerve  and  superior  profunda  artery  cross 
the  back  of  the  bone. 

255 


256  SURGICAL    APPLIED    ANATOMY      [Part  III 

When  the  arm  is  extended  and  supinated,  the 
brachial  artery  corresponds  to  a  line  drawn  along 
the  inner  border  of  the  biceps,  from  the  outlet  of 
the  axilla  (at  the  junction  of  its  middle  and  an- 
terior thirds)  to  the  middle  of  the  bend  of  the 
elbow.  The  artery  is  superficial,  and  can  be  felt 
in  its  entire  extent.  In  its  upper  two-thirds  it 
lies  on  the  inner  aspect  of  the  shaft  of  the 
humerus,  and  can  be  compressed  against  the  bone 
by  pressure  in  a  direction  outwards  and  slightly 
backwards.  In  its  lower  third  the  humerus  lies 
behind  it,  and  compression,  to  be  effectual,  should 
be  directed  backwards. 

The  inferior  profunda  would  be  represented 
by  a  line  drawn  from  the  inner  side  of  the 
humeral  shaft  at  its  middle  to  the  back  part  of 
the  internal  condyle.  The  nutrient  artery  enters 
the  bone  at  its  inner  aspect  opposite  the  deltoid 
insertion,  and  the  anastomotic  vessel  comes  off 
about  2  inches  above  the  bend  of  the  elbow. 

The  ulnar  nerve  follows  first  thet  brachial 
artery,  and  then  a  line  drawn  from  the  inner  side 
of  that  vessel,  about  the  level  of  the  insertion  of 
the  coraco-brachialis,  to  the  gap  between  the  inner 
condyle  and  the  olecranon.  The  main  part  of  the 
internal  cutaneous  nerve  is  beneath  the  inner 
bicipital  groove,  while  the  musculo-cutaneous 
nerve  becomes  superficial  in  the  bend  of  the  elbow 
at  the  outer  margin  of  the  tendon  of  the  biceps. 

The  arm. — The  skin  of  the  arm  is  thin  and 
smooth,  especially  in  front  and  at  the  sides.  It 
is  very  mobile,  being  but  loosely  attached  to  the 
deeper  parts  by  a  lax  subcutaneous  fascia.  In 
circular  amputations  of  the  arm  this  looseness  of 
the  integument  allows  it  to  be  sufficiently^  drawn 
up  by  traction  with  the  hand  only.  It  is  from 
the  integument  covering  the  anterior  surface  of 
the  biceps  that  the  flap  is  fashioned  in  Taglia- 
cozzi's  operation  for  the  restoration  of  the  nose. 
The  fineness  of  the  skin  of  this  part,  and  its  free- 
dom from  hairs,  render  it  very  suitable  for  this 
procedure.     The    scanty   attachments    of  the   skin 


Chap.  XII]  THE    AEM  257 

of  the  arm  allow  it  to  be  readily  torn  or  stripped 
away  in  lacerated  and  contused  wounds.  Some- 
times in  these  lesions  large  flaps  of  integument 
are  violently  dissected  up.  The  looseness  of  the 
subcutaneous  tissues  favours  greatly  the  spread 
of  inflammatory  processes,  while  its  comparative 
thinness  allows  of  the  early  manifestation  of 
ecchymoses. 

The  limb  is  completely  invested  with  a  deep 
fascia,  the  brachial  aponeurosis,  as  by  a  sleeve. 
The  fascia  is  held  down  at  the  sides  by  the  two 
intermuscular  septa  which  are  attached  along  the 
outer  and  inner  margins  of  the  humerus,  running 
from  the  deltoid  insertion  to  the  outer  condyle  on 
the  one  side,  and  from  the  coraco-brachialis  inser- 
tion to  the  inner  condyle  on  the  other.  By  means 
of  this  aponeurosis  and  its  septa  the  arm  is 
divided  into  two  compartments,  that  can  be  well 
seen  in  transverse  sections  of  the  limb  (Fig.  44, 
p.  261).  These  compartments  serveto  confine  in- 
flammatory and  hemorrhagic  effusions.  The  an- 
terior of  the  two  spaces  has  the  less  substantial 
boundaries,  owing  to  the  thinness  of  the  brachial 
fascia  as  it  covers  the  biceps.  Effusions  can 
readily  pass  from  one  compartment  to  the  other 
by  following  the  course  of  those  structures  that, 
by  piercing  the  intermuscular  septa,  are  common 
to  both  spaces.  These  are  the  musculo-spiral  and 
ulnar  nerves,  the  superior  and  inferior  profunda, 
and  anastomotic  arteries.  The  principal  struc- 
tures that  pierce  the  brachial  aponeurosis  itself 
are  the  basilic  vein,  a  little  below  the  middle  of 
the  arm,  the  internal  cutaneous  nerve,  about  the 
middle,  and  the  external  cutaneous  nerve,  at  the 
elbow.  The  two  first-named  are  in  the  inner 
bicipital  groove,  and  the  last-named  in  the  outer. 

The  brachialis  anticus  is  closely  adherent  to 
the  bone,  while  the  biceps  is  free.  It  follows, 
therefore,  that  in  section  of  these  muscles,  as  in 
amputation,  the  latter  muscle  retracts  more  con- 
siderably than  does  the  former.  It  is  well,  there- 
fore,   in   performing    a   circular    amputation,    to 


258  SUEGICAL    APPLIED    ANATOMY      [Part  III 

divide  the  biceps  muscle  first,  and  then,  after  it 
has  retracted,  to  cut  the  brachialis  anticus. 

The  brachial  artery* — The  line  of  this  vessel 
has  already  been  given.  It  is  well  to  note  that 
in  the  very  muscular  the  artery  may  be  over- 
lapped to  a  considerable  extent  by  the  biceps 
muscle.  Compression  of  the  brachial,  unless  per- 
formed carefully  with  the  fingers,  can  hardly 
avoid  at  the  same  time  compression  of  the  median 
nerve.  It  must  also  be  remembered  that  the  in- 
ternal cutaneous  nerve  lies  in  front  of  the  vessel, 
or  close  to  its  inner  side,  until  it  pierces  the 
fascia;  that  the  ulnar  nerve  lies  along  the  inner 
side  of  the  artery  as  far  as  the  coraco-brachialis 
insertion ;  and  that  behind  the  commencement  of 
the  vessel  is  the  musculo-spiral  nerve.  The  venae 
comites  are  placed  one  on  either  side  of  the  artery, 
and  communicate  frequently  with  one  another  by 
short  transverse  branches  which  directly  cross  the 
vessel,  and  which  may  give  trouble  in  operations 
upon  the  artery.  If  in  ligaturing  the  artery  at 
its  middle  third  the  arm  rests  upon  any  support, 
the  triceps  may  be  pushed  up  and  mistaken  for 
the  biceps.  If  the  incisions  be  too  much  to  the 
inner  side  the  basilic  vein  may  be  cut,  or  the 
ulnar  nerve  exposed  and  mistaken  for  the  median. 
Tillaux  states  that  in  the  operation  a  large  in- 
ferior profunda  artery  has  been  taken  for  the 
brachial.  Inasmuch  as  the  median  nerve  often 
derives  distinct  pulsation  from  the  subjacent  ves- 
sel, it  happens  that  in  the  living  subject  it  has 
been  confused  with  the  main  artery  itself. 

Abnormalities  in  the  arrangement  of  the 
brachial  artery  are  so  frequent  (they  occur  in  12 
to  15  per  cent._  of  arms)  as  to  be  of  surgical  im- 
portance. It  is  not  unusual  to  find  a  collateral 
branch  (vas  aberrans)  arising  from  the  upper 
part  of  the  brachial  or  lower  part  of  the  axillary, 
passing  down  the  arm,  superficially  to  the  median 
nerve,  and  ending  in  the  radial  or  sometimes  the 
ulnar  artery.  The  vas  aberrans  may  replace  the 
brachial,  in  which  case  the  artery  will  be  found 


Chap.  XII]  THE    ARM  259 

superficial  instead  of  deep  to  the  median  nerve, 
and  the  profunda  vessels  arise  from  the  remnant 
of  the  real  brachial  artery.  This  superficial 
brachial  vessel  may  pass  under  the  supra- 
condyloicl  process,  a  hooked  projection  of  bone 
which  occasionally  springs  from  the  humerus,  2 
inches  above  the  epicondyle.  It  is  situated 
amongst  the  inner  fibres  of  origin  of  the  brachialis 
anticus. 

The  iiiusculo-spiral  nerve,  from  its  close 
contact  with  the  bone,  which  it  crosses  at  the  level 
of  the  deltoid  insertion,  is  frequently  injured  and 
torn.  Thus  it  has  been  damaged  in  severe  con- 
tusions, in  kicks,  in  stabs,  in  bites  from  horses, 
and  very  frequently  in  fractures  of  the  humeral 
shaft;  or  the  nerve  may  be  sound  at  the  time  of 
fracture,  and  become  subsequently  so  involved 
in  the  callus  formed  as  to  lead  to  paralysis  of  the 
parts  it  supplies.  In  a  case  reported  by  Tillaux, 
where  paralysis  followed  some  time  after  a  frac- 
ture, the  nerve  was  found  embedded  in  callus,  and 
on  cutting  some  of  the  redundant  mass  away  a 
good  recovery  followed.  In  several  instances  the 
nerve  has  been  paralysed  by  the  pressure  of  the 
head  when  a  man  has_  slept  with  his  head  resting 
on  the  arm  in  the  position  of  full  supination  and 
abduction.  It  is  said  to  be  often  paralysed  in 
Russian  coachmen  who  fall  asleep  with  the  reins 
wound  round  the  upper  arm.  It  has  also  been 
frequently  damaged  by  the  pressure  of  badly  con- 
structed crutches,  especially  those  that  afford  no 
proper  support  for  the  hand.  Indeed,  it  is  the 
nerve  most  often  affected  in  "  crutch  paralysis," 
the  ulnar  being  the  trunk  that  suffers  next  in 
frequency. 

Fracture  of  the  shaft  of  the  humerus  is 
usually  due  to  direct  _  violence.  The  shaft  may, 
however,  be  broken  by  indirect  violence,  and  of  all 
bones  the  humerus  is  said  to  be  the  one  most 
frequently  fractured  by  muscular  action.  As  ex- 
amples of  the  latter  may  be  noted  the  throwing 
of  a  ball,  the  clutching  at  a  support  to  prevent  a 


260  SURGICAL    APPLIED    ANATOMY      [Part  III 

fall,  and  the  so-called  trial  of  strength  known  as 
"  wrist-turning."  When  the  bone  is  broken  above 
the  deltoid  insertion  the  lower  fragment  may  be 
drawn  upwards  by  the  biceps,  triceps,  and  del- 
toid, and  outwards  by  the  last-named  muscle; 
while  the  upper  fragment  is  drawn  inwards  by  the 
muscles  attached  to  the  bicipital  groove.  When 
the  fracture  is  below  the  ■  deltoid  insertion,  the 
lower  end  of  the  upper  fragment  may  be  carried 
outwards  by  that  muscle,  while  the  lower  frag- 
ment is  drawn  upwards  to  its  inner  side  by  the 
biceps  and  triceps.  The  deformity,  however,  as 
a  rule  depends  much  more  upon  the  nature  and 
direction  of  the  force  that  breaks  the  bone  than 
upon  any  muscular  action.  The  displacements 
just  noted  may  be  met  with,  but  usually  they  are 
quite  independent  of  the  relation  of  the  deltoid 
insertion  to  the  seat  of  fracture,  and  cannot  be 
tabulated.  The  weight  of  the  arm  seldom  allows 
of   more   than   §   of   an   inch   of   shortening. 

The  humerus  is  more  frequently  the  seat  of 
non-union  after  fracture  than  is  any  other  bone. 
This  result  is  quite  independent  of  the  position 
of  the  fracture  in  relation  to  the  nutrient  artery. 
Hamilton's  explanation  is  briefly  this  :  The  frac- 
ture is  usually  so  adjusted  that  the  elbow  is 
flexed;  this  joint  soon  becomes  fixed  by  muscular 
rigidity,  and  when  any  movement  is  made  as  if 
to  flex  or  extend  the  forearm  on  the  arm,  that 
movement  no  longer  occurs  at  the  elbow- joint,  but 
at  the  seat  of  fracture.  Thus,  if  the  arm  be  in 
a  sling,  and  the  patient  allows  the  hand  to  drop 
by  relaxing  that  sling,  it  is  maintained  that  the 
bulk  of  that  movement  will  take  place  about  the 
fracture  line.  There  are  many  objections  to  this 
theory.  If  true,  the  tendency  to  movement  about 
the  fragments  would  be  the  greater  the  farther 
the  fracture  is  from  the  elbow- joint,  but  non- 
union is  more  common  at  the  middle  than  at  the 
upper  third  of  the  shaft.  Probably  many  causes 
conspire  to  bring  about  non-union  of  fractures 
of  this  bone,  among  which  may  be  mentioned  the 


Chap.  XII] 


THE   ARM 


261 


imperfect  fixing  of  the  joint  above  the  fracture, 
and  the  inadequate  support  afforded  to  the  elbow, 
whereby  the  weight  of  the  arm  and  of  the  splints 
tends  to  drag  the  lower  fragment  out  of  the 
proper  line  it  should  form  with  the  upper  frag- 
ment. The  most  effective  cause  would  appear  to 
be  the  entanglement  of  muscular  tissue  between 
the  broken  ends,  for  it  must  be  remembered 
that  the  shaft  of  the  bone  is  closely  surrounded  by 
muscular  fibres  that  are  directly  adherent  to  its 
surfaces.  Thus,  in  an  oblique  fracture  the  end  of 
one  fragment  may  be  driven  into  the  brachialis 
anticus,  while  the  other  end  projects  into  the  sub- 
stance of  the  triceps,  and  immediate  contact  of 
the  bones  may  be  consequently  prevented. 

Amputation  through  the  middle  of  the 
arm.  — Circular  method:  The  parts  divided  in 
this  amputation  are  fully  shown  in  Fig.  44.  Flap 
method  :  Two 
flaps  of  about 
equal  size  and 
shape  may  be  cut 
antero-posterior- 
ly,  the  arm  being 
well  rotated  out- 
wards. In  the  an- 
terior flap  would 
be  the  biceps  and 
the  greater  part 
of  the  brachialis 
anticus,  with  the 
musculo  -  cutane- 
ous nerve  between 
them,  and  a  small 
piece  of  the  tri- 
ceps from  the 
inner  side  of  the 
limb.  The  bra- 
chial vessels,  the 
median  and  ul- 
nar nerves,  and  possibly  the  inferior  profunda 
artery,    are   also    found    in    this   flap,    about    the 


Fig.  44. — A  transverse   section  through  the 
middle  of  the  arm.     (Braune.) 

a,  Biceps  ;  b,  coraco  -  brachialis  ;  c,  brachialis 
anticus  ;  d,  triceps ;  1,  brachial  artery ;  2,  me- 
dian nerve ;  3,  ulnar  nerve  ;  4,  muscuio-spiral 
nerve. 


262  SUKGICAL   APPLIED   ANATOMY     [Part  III 

inner  angle  of  the  stump.  The  basilic  vein  and 
internal  cutaneous  nerve  lie  about  the  inner 
border  of  the  anterior  flap,  and  the  cephalic  vein 
about  its  outer  border.  In  the  posterior  flap 
would  be  the  triceps,  any  small  part  of  the  outer 
portion  of  the  brachialis  not  included  in  the 
anterior  flap,  the  superior  profunda  artery,  and 
the  musculo-spiral  nerve.  If  the  amputation  be 
lower  down  in  the  arm,  the  ulnar  nerve  and  in- 
ferior profunda  artery  may  be  found  in  the  pos- 
terior instead  of  the  anterior  flap. 


CHAPTER   XIII 

THE    REGION    OF    THE    ELBOW 

Surface  anatomy. — On  the  anterior  aspect  of 
the  elbow  are  seen  three  muscular  elevations. 
One,  above  and  in  the  centre,  corresponds  to  the 
biceps  and  its  tendon ;  while,  of  the  two  below  and 
at  the  sides,  the  outer  corresponds  to  the  supina- 
tor longus  and  the  common  extensor  mass,  and  the 
inner  to  the  pronator  radii  teres  and  the  common 
set  of  flexor  muscles.  The  arrangement  of  these 
elevations  is  such  that  two  grooves  are  formed, 
one  on  either  side  of  the  biceps  and  its  tendon. 
The  grooves  diverge  above,  and  join  the  outer  and 
inner  bicipital  grooves,  while  below  they  meet 
over  the  most  prominent  part  of  the  tendon,  and 
thus  form  together  a  Y-shaped  depression  (Fig. 
45).  The  distinctness  of  these  details  depends 
upon  the  thinness  and  muscular  development  of 
the  individual.  In  the  inner  of  the  two  grooves 
are  to  be  found  the  median  nerve,  the  brachial 
artery  and  its  veins;  while  deeply  placed  below 
the  outer  groove  are  the  terminations  of  the  mus- 
culo-spiral  nerve  and  superior  profunda  artery, 
with  the  small  radial  recurrent  vessel.  The  biceps 
tendon  can  generally  be  very  distinctly  felt.  Its 
outer  border  is  more  evident  than  is  its  inner 
edge,  owing  to  the  connection  of  the  bicipital 
fascia  with  the  latter  side  of  the  tendon.  Extend- 
ing transversely  across  the  front  of  this  region  is 
a  crease  in  the  integument,  the  "  fold  of  the 
elbow."     This  fold  is  not  a  straight  line,   but  is 

263 


264  SURGICAL    APPLIED    ANATOMY      [Part  III 

convex  below.  It  is  placed  some  little  way  above 
the  line  of  the  articulation,  and  its  lateral  ter- 
minations correspond  to  the  tips  of  the  two  con- 
dylar eminences.  In  backward  dislocations  of  the 
elbow  the  lower  end  of  the  humerus  appears  about 
1  inch  below  this  fold,  whereas  in  a  fracture  of 
the  humerus  just  above  the  condyles  the  fold  is 
either  opposite  to  the  prominence  formed  by  the 
lower  end  of  the  upper  fragment,  or  is  below  it. 
This  crease  is  obliterated  on  extension. 

At  the  apex  of  the  V-shaped  depression,  about 
the  spot  where  the  biceps  tendon  ceases  to  be  dis- 
tinctly felt,  and  at  the  outer  side  of  that  tendon, 
the  median  vein  divides  into  the  median  basilic 
and  the  median  cephalic.  At  the  same  spot  also 
the  deep  median  vein  joins  the  superficial  vessels. 
The  median  basilic  vein  can  be  seen  to  cross  the 
biceps  tendon,  to  follow  more  or  less  closely  the 
groove  along  the  inner  border  of  the  muscle,  and 
to  join,  a  little  above  the  internal  condyle,  with 
the  posterior  ulnar  vein  to  form  the  basilic  trunk. 
The  median  cephalic,  following  the  groove  at  the 
outer  margin  of  the  biceps,  joins,  about  the  level 
of  the  external  condyle,  with  the  radial  vein  to 
form  the  cephalic  vein.  The  brachial  artery 
bifurcates  1  inch  below  the  centre  of  a  line  drawn 
from  one  condyle  to  the  other;  the^  point  of 
division  is  opposite  the  neck  of  the  radius.  "  The 
coronoid  process  of  the  ulna  can  be  indistinctly 
felt,  if  firm  pressure  is  made  in  the  triangular 
space  in  front  of  the  joint  "  (Chiene).  The  points 
of  the  two  condyles  can  always  be  felt.  The  in- 
ternal condyle  is  the  more  prominent  and  the  less 
rounded  of  the  two.  The  humero-radial  articula- 
tion forms  a  horizontal  line,  but  the  humero-ulnar 
joint  is  oblique,  the  joint  surfaces  sloping  down- 
wards and  inwards.  _  Thus  it  happens  that  while 
the  external  condyle  is  only  f  of  an  inch  (18  mm.) 
above  the  articular  line,  the  point  of  the  internal 
condyle  is  more  than  1  inch  (28  mm.)  above  that 
part  (Paulet).  From  the  obliquity  of  the  joint 
surfaces  between  the  ulna  and  humerus,  it  follows 


Chap.  XIII]         REGION    OF    THE    ELBOW  265 

that  the  forearm,  when  in  extension,  is  not  in  a 
straight  line  with  the  upper  arm,  but  forms  with 
it  an  angle  that  opens  outwards.  Thus,  when 
traction  is  made  upon  the  entire  upper  limb  from 
the  wrist,  some  of  the  extending  force  is  neces- 
sarily lost,  and  such  traction,  therefore,  should 
be  applied  from  the  elbow,  as  is  the  usual  practice 
in  reducing  a  dislocation  of  the  shoulder  by 
manipulation.  A  line  drawn  through  the  two 
condyles  will  be  at  right  angles  with  the  axis  of 
the  upper  arm,  while  it  will  form  externally  a 
smaller  angle  with  the  axis  of  the  forearm.  Thus, 
if  we  look  at  the  upper  arm,  the  two  condyles  are 
on  the  same  level,  whereas,  when  viewed  from  the 
forearm,  the  inner  condyle  lies  at  a  higher  level 
than  doest  the  external  process.  _ 

The  joint  line  of  the  elbow  is  equivalent  only 
to  about  two-thirds  of  the  width  of  the  entire  line 
between  the  points  of  the  two  condyles  (Fig.  46, 
p.  270).  The  prominence  of  the  condyles  forms  a 
capital  point  d'appui  for  traction  by  encircling 
bands  applied  to  the  limb  above  the  elbow-joint. 
At  the  back  of  the  elbow  the  prominence  of  the 
olecranon  is  always  to  be  distinctly  felt.  It  lies 
nearer  the  internal  than  the  external  condyle.  In 
extreme  extension  the  summit  of  the  olecranon 
is  a  little  above  the  line  joining  the  two  condyles. 
When  the  forearm  is  at  right  angles  with  the  arm, 
the  tip  of  the  process  is  below  the  line  of  the 
condyles,  and  in  extreme  flexion  it  lies  wholly 
in  front  of  that  line.  Between  the  olecranon  and 
the  inner  condyle  is  a  depression  that  lodges  the 
ulnar  nerve  and  the  posterior  ulnar  recurrent 
artery. 

To  the  outer  side  of  the  olecranon,  and  just 
below  the^  external  condyle,  there  is  a  depression 
in  the  skin  which  is  very  obvious  when  the  limb 
is  extended.  This  pit  is  to  be  seen  even  in  those 
who  are  fat,  and  also  in  young  children.  In  it 
the  head  of  the  radius  and  radio-humeral  joint 
can  be  felt,  and  can  be  well  distinguished  when 
the  bone  is  rotated  in  pronation  and  supination. 


266 


SURGICAL   APPLIED    ANATOMY      [Part  III 


The  pit  corresponds  to  the  hollow  between  the 
outer  border  of  the  anconeus  and  the  muscular 
eminence  formed  by  the  two  radial  extensors  of 
the  carpus  and  the  supinator  longus.  The  highest 
point  of  the  bone  that  can  be  felt  ^  moving  on 
rotation  will  correspond  to  the  radius  immedi- 
ately below  the  line  of 
the  elbow-joint,  and  is  a 
valuable  guide  to  that 
articulation.  The  upper 
limit  of  the  elbow-joint 
reaches  a  line  drawn  be- 
tween the  point  of  the  two 
condyles.  The  tubercle  of 
the  radius  can  be  felt  just 
below  the  head  of  the  bone 
when  the  limb  is  in  the 
position  of  extreme  pro- 
nation. 

The  region  of  the 
el  how. — The  skin  in  front 
of  the  elbow  is  thin  and 
fine,  and  is  readily  ex- 
coriated by  tight  bandag- 
ing and  by  improperly 
applied  splints.  The;$hin- 
ness  of  the  skin  allows  the 
subjacent  veins  to  be 
easily  seen  through  the 
integuments,  but  the  dis- 
tinctness with  which  these 
veins  appear  depends 
mainly  upon  the  amount 
of  subcutaneous  fat.  In 
the  very  stout  they  may 
be  quite  invisible,  and  it 
may  be  difficult  or  im- 
possible to  render  them 
evident  by  the  usual  means 
Tillaux  points  out  that  if 
suchpeople  are  bled  a  pellet  of  fat  will  often  pro- 
ject into  the  wound  and  prevent  the  flow  of  blood. 


Fig.   45.— The    left    elbow  from 
in  front. 

a,  Basilic  vein  ;  b,  cephalic  vein ; 
o,  on  the  ulna  points  to  median 
basilic  vein:  d,  on  the  radius 
points  to  median  cephalic  vein ; 
e,  radial  vein  ;  /,  median  vein  ; 
0,  posterior  ulnar  vein.  The 
brachial  artery  passes  behind 
the  median-basilic  vein,  and 
divides  into  its  radial  and  ulnar 
branches  to  the  inner  side  of 
the  radial  neck. 

adopted  in  venesection. 


Chap.  XIII]        REGION    OP   THE    ELBOW  267 

The  arrangement  of  the  superficial  veins  in 

front  of  the  elbow,  so  as  to  form  an  M-shaped 
figure,  is  familiar,  but  it  must  be  confessed  that 
it  is  by  no  means  constant  (Fig.  45).  So  far  as  I 
have  seen,  it  would  appear  that  the  precise  M-like 
arrangement  figured  in  most  books  is  only  present 
in  about  two-thirds,  and  perhaps  in  only  one- 
half,  of  all  cases. 

The  median  vein  breaks  up  into  the  median 
cephalic  and  median  basilic,  just  to  the  outer 
side  of  the  biceps  tendon,  and,  therefore,  the 
latter  vein  passes  in  front  of  the  tendon,  of  the 
brachial  artery  and  its  veins,  and  of  the  median 
nerve.  From  these  structures  it  is  separated  by 
the  bicipital  fascia.  The  median  basilic  vein  may 
cross  the  brachial  artery  abruptly,  and  be  com- 
paratively free  of  it,  except  at  the  point  of  cross- 
ing, or  it  may  run  for  some  distance  quite  in 
front  of  the  artery,  or,  crossing  it  early,  it  may 
lie  parallel  with  the  vessel,  although  at  a  different 
level,  for  the  greater  part  of  its  course.  As  re- 
gards size,  the  median  basilic  is  usually  the 
largest  of  these  veins,  the  median  cephalic  coming 
next,  and  the  median  itself  third,  while  the  ulnar 
and  radial  veins  are  the  smallest  of  the  series. 
These"-  veins  are  liable  to  many  abnormalities, 
some  of  the  most  conspicuous  being  in  cases  where 
the  main  arteries  of  the  part  also  are  abnormal. 
The  deviation  is  more  usual  in  the  veins  on  the 
radial  than  in  those  on  the  ulnar  side  of  the  limb. 
Thus  it  is  common  for  the  radial  or  the  median 
cephalic  veins,  or  both,  to  be  either  very  defec- 
tive or  entirely  absent.^  In  spite  of  the  relation 
the  median  basilic  vein  bears  to  the  brachial 
artery,  it  is  nevertheless  the  vein  usually  selected 
in  venesection  and  transfusion.  The  reasons  for 
its  selection  are  these  :  it  is  usually  the  largest 
and  most  prominent  of  the  veins,  and  the  one 
the  nearest^  to  the  surface ;  it  is  also  the  least 
movable  vein,  and  vthe  one  the  least  subject  to 
variation.  The  bicipital  fascia  forms  an  excel- 
lent   protection    to    the    brachial    artery    during 


268  SURGICAL   APPLIED    ANATOMY      [Part  III 

phlebotomy.  •  The  density  of  that  membrane 
varies,  and  depends  mainly  upon  the  degree  of 
muscular  development.  In  thin  subjects  the 
median  basilic  vein  may  receive  pulsations  from 
the  subjacent  artery.  According  to  one  observer, 
the  walls  of  this  vein  are  often  as  thick  as  those 
of  the  popliteal  vein.^  The  ulnar,  radial,  and 
median  veins  seldom  yield  enough  blood  on  vene- 
section, since  they  are  below  the  point  of  junction 
of  the  deep  median  vein,  and  thus  do  not  receive 
blood  from  the  deep  veins  of  the  limb.  The 
brachial  artery  has,  as  may  be  supposed,  been 
frequently  injured  in  bleeding;  and  at  the  period 
when  venesection  was  very  commonly  practised, 
arterio-venous  aneurisms  at  the  bend  of  the  elbow 
were  not  infrequent.  Since  the  principal  super- 
ficial lymphatic  vessels  run  with  these  veins,  and 
since  some  of  them  can  scarcely  escape  injury  in 
phlebotomy,  it  follows  that  an  acute  lymphan- 
gitis is  not  uncommon  after  the  operation,  especi- 
ally when,  the  point  of  the  lancet  being  unclean, 
septic  matter  is  introduced  into  the  wound. 

The  internal  cutaneous  nerve,  which  usually 
runs  in  front  of  the  median  basilic  vein,  may  be 
wounded  in  bleeding  from  that  vessel.  The  in- 
jury to  the  nerve,  according  to  Tillaux,  may  lead 
to  "  traumatic  neuralgia  of  extreme  intensity, 
and  very  chronic."  A  "  bent  arm  "  may  follow 
after  venesection,  and  Mr.  Hilton  believes  this 
to  be  often  due  to  injury  to  the  filaments  of  the 
musculocutaneous  nerve,  especially  to  the  inclu- 
sion of  those  filaments  in  a  scar  left  by  the  opera- 
tion. The  cutaneous  branches  of  this  nerve  lie 
over  the  median  cephalic  vein.  These  peripheral 
fibres  being  irritated,  the  muscles  supplied  from 
the  same  segment  of  the  cord  (biceps  and 
brachialis  anticus)  are  caused  to  contract  by  re- 
flex action.  Hence  the  bent  arm.  In  one  case  he 
cured  a  bent  arm  following  bleeding  by  resecting 
the  old  scar,  which  on  removal  was  found  to 
have  included  within  its  substance  some  nerve 
filaments. 


Chap.  XIII]         REGION    OF    THE    ELBOW  269 

There  is  a  lymphatic  gland  situated  over  the 
internal  intermuscular  septum  of  the  arm,  and 
just  above  the  internal  condyle.  It  receives  some 
of  the  surface  lymphatics  from  the  inner  side  of 
the  forearm,  and  two  or  three  inner  fingers.  In 
position,  it  is  the  lowest  of  the  constant  glands  in 
the  upper  limb. 

The  brachial  artery. — In  forcible  flexion  of 
the  limb  the  artery  is  compressed  between  the 
muscular  masses  in  front  of  the  joint,  and  the 
radial  pulse  is  much  diminished  or  even  checked. 
The  artery  may  divide  in  the  lower  third  of  the 
arm,  and  in  such  cases  the  ulnar  artery  may  pass 
over  the  bicipital  fascia.  Aneurisms  at  the  bend 
of  the  elbow  have  been  treated  by  flexion  of  the 
limb,  that  position  bringing  more  or  less  direct 
pressure  to  bear  upon  the  sac.  In  full  extension 
of  the  joint  the  artery  becomes  flattened  out,  and 
the  radial  pulse  diminished.  In  the  over-ex- 
tension possible  with  fractured  olecranon  the 
pulse  may  be  stopped  at  the  wrist.  Forcible  ex- 
tension of  an  elbow  that  has  become  rigid  in  the 
bent  position  has  caused  rupture  of  the  brachial 
artery. 

The  ulnar  nerve  is,  from  its  position  at  the 
elbow,  very^  liable  to  be  injured.  It  passes  in  a 
groove  behind  the  internal  epicondyle,  and  is 
crossed  by  a  bridge  of  fibrous  tissue  which  pre- 
vents its  displacement.  The  nerve  may  pass  in 
front  of  the  internal  condyle,  and  an  instance 
is  reported  where  the  nerve  slipped  forward  over 
that  eminence  whenever  the  elbow  was  bent 
(Quain).  In  cases  where  an  abnormal  brachial 
passes  beneath  a  supracondyloid  process  the 
median  nerve  goes  with  the  artery.  In  exposing 
the  ulnar  nerve  (for  nerve-stretching,  etc.)  behind 
the  elbow  the  nerve  may  be  found  quite  covered  by 
an  occasional  muscle,  the  epitrochleo-anconeus. 

The  elbow-joint.  —  The  strength  of  this  joint- 
depends  not  so  much  upon  either  ligaments  or 
muscles  as  upon  the  coaptation  of  the  bony  sur- 
faces.   The  relations  of  the  olecranon  and  coronoid 


270 


SURGICAL    APPLIED    ANATOMY     [Part  III 


processes  to  the  humerus  are  such  that  in  certain 
positions  the  strength  of  the  joint  is  very  con- 
siderable. 

The  elbow,  being  a  pure  hinge-joint,  permits 
only  of  flexion  and  extension.  These  movements 
are  oblique,  so  that  in  flexion  the  forearm  in- 
clines  inwards,    carrying   the   hand   towards   the 


Triceps 


OLECRAnO/S 


Ulha 


HUMERUS 

Biceps 

BRACKIALI5  ArtTICUS 

Capsule 

Sup.  Lo/icus. 
Epipmysis  of  Trochlea 

ro/noid 

E-URSA 

Biceps 
Iaiterosseus  Ae.t. 


Fig.  46. — Vertical  section  of  the  elbow-joint. 


The  epiphyseal  lines  of  the  olecranon  and  trochlea  are.  shown  in  red.    The  joint 
is  semi-extended. 

A,  Usual  cap-like  epiphysis  of  olecranon  receiving  insertion  of  triceps ;  B,  occa- 
sional epiphysis  forming  the  upper  third  of  the  olecranon.  Three  bursas  are 
shown— over  the  olecranon,  under  the  insertion  of  the  triceps,  and  at  the 
insertion  of  the  biceps. 

middle  third  of  the  clavicle.  If  it  were  not  for 
the  obliquity  of  the  joint  line  it  would  be  possible 
for  the  hand  to  be  placed  flat  upon  the  shoulder 
of  the  same  side,  but  this  movement  is  only  possi- 
ble after  some  excisions  of  the  joint,  for  in  this 
operation  the  oblique  direction  of  the  articular 
surfaces  is  not  reproduced.  In  extreme  extension 
the  ulna  is  nearly  in  a  straight  line  with  the 
humerus   as   regards  their   lateral   planes,   while 


Chap.  XIII]         REGION    OF    THE    ELBOW  271 

in  extreme  flexion  the  two  bones  form  an  angle 
of  from  30°  to  40°. 

Bursa?.  —  Of  the  bursse  about  the  joint  the 
large  subcutaneous  bursa  over  the  olecranon  is 
very  commonly  found  enlarged  and  inflamed 
(Fig.  46) ;  and  when  inflamed  may  lead  to  exten- 
sive mischief  in  the  limb.  Its  enlargement  is 
favoured  by  certain  employments  involving  pres- 
sure on  the  elbow ;  thus,  the  disease  known  as 
"  miner's  elbow  "  is  merely  an  enlargement  of  this 
sac.  There  is  a  bursa  between  the  biceps  tendon 
at  its  insertion  and  the  bone,  the  relations  of  which 
to  the  nerves  of  the  forearm  are  worth,  noting. 
A  case,  for  instance,  is  reported  where  this  bursa 
became  chronically  enlarged,  and  by  pressing 
upon  the  median  and  posterior  interosseous 
nerves  produced  loss  of  power  in  the  forearm 
(Agnew).  There  is  a  small  bursa  at  the  insertion 
of  the  triceps  (Fig.  46). 

Of  the  ligaments  of  the  elbow-joint,  the  an- 
terior and  posterior  are  comparatively  thin,  and 
the  latter  especially^  soon  yields  to  the  pressure  of 
fluid  within  the  joint  in  disease  of  the  articula- 
tion (Fig.  46).  The  internal  lateral  is  the  strong- 
est and  most  extensive  of  the  ligaments  of  the 
part.  From  its  rigidity,  its  extended  attachment, 
and  the  fact  that  it  serves  to  limit  not  only 
flexion  and  extension,  but  also  any  attempt  to 
wrench  the  forearm  laterally  from  the  arm,  it 
happens  that  it  is  the  ligament  that  suffers  the 
most  often  in  "  sprains  "  of  the  elbow.  As  this 
ligament  is  attached  to  the  whole  length  of  the 
inner  border  of  the  olecranon,  it  may  assist  in 
preventing  separation  of  the  fragments  when  that 
process  has  been  fractured. 

Joint  disease. — In  disease  of  this  joint  the 
effusion  first,  and  most  distinctly,  shows  itself 
by  a  swelling  around  the  margins  of  the  ole- 
cranon. This  is  explained  by  the  facts  that  the 
synovial  cavity  is  here  nearest  to  the  surface,  and 
that  the  posterior  ligament  is  lax  and  thin  (Fig. 
46).     Some  swelling  is  also  soon  noticed. about  the 


272  SUEGICAL    APPLIED    ANATOMY      [Part  III 

line  of  the  radio-humeral  joint,   and  fluctuation 
in  this  situation  serves  to  distinguish  joint  effu- 
sion from  simple  enlargement  of  the  bursa  beneath 
the  triceps  tendon.     Deep-seated  swelling  may  be 
noted   about  the   front  of  the   joint  beneath   the 
brachialis  anticus,   owing  to  the  thinness  of  the 
anterior  ligament;  and  lastly,  about  the  external 
condyle.     The    density   of   the   internal   ligament 
prevents  a  bulging  of  the  synovial  membrane  on 
the   inner   side.     When   the  joint  suppurates  the 
pus  will  most  easily  reach  the  surface  by  travel- 
ling upwards  and  backwards  between  the  humerus 
and  the  triceps,  and  the  abscess  points,  therefore, 
very   commonly   at  one   or   other   border   of   that 
muscle.     The  pus  may  escape  beneath  the  brachi- 
alis anticus  in  front,  and  discharge  itself  near  the 
insertion  of  the  muscle.     The  diseased  elbow  tends 
to  assume  the  posture  of  semi-flexion,   and  it  is 
interesting  to   observe  that  that  is  the   position 
assumed    by   the    joint    when    forcible    injections 
are  made  into  its  cavity  (Braune).     The  joint,  in 
fact,  holds  the  greatest  amount  of  fluid  when  it 
is   semi-flexed.     As  regards  muscular  rigidity  of 
the  elbow,   due  to  reflex  irritation  from  disease, 
it  is  well  to  note  that  all  the  nerves  of  the  articu- 
lation supply  muscles  acting  upon  the  joint,  not- 
ably  the   musculo-spiral   and   musculo-cutaneous. 
The  relation  of  the  ulnar  nerve  to  the  joint  serves 
to  explain  cases  where  severe  pain  has  been  felt 
along  the   forearm  and   in   the  fingers,    in   parts 
corresponding  to  the  distribution  of  that  nerve. 
The  upper  epiphysis  of  the  radius  and  the  greater 
part  of  the  lower  epiphysis  of  the  humerus  are 
intrasynovial,  i.e.  come  within  the  capsule  of  the 
joint  (Fig.   47).     The  comparatively  small  upper 
epiphysis  of  the  ulna  is  only  partly  within  the 
capsule  (Fig.   46). 

Dislocations  of  the  elbow.— These  are  many, 
and  may  be  thus  arranged.  (1)  Dislocations  of 
both  radius  and  ulna  either  backwards,  outwards, 
inwards,  or  forwards  (in  order  of  frequency). 
(2)  Dislocations  of  the  radius  alone  either  for- 


Ohap.  XIII]         EEGION    OF    THE    ELBOW  273 

wards,  backwards,  or  outwards  (in  order  of  fre- 
quency). (3)  Luxation  of  the  ulna  alone  back- 
wards. 

As  a  preliminary  it  may  be  convenient  to  note 
some  general  anatomical  considerations  in  con- 
nection with  these  various  displacements. 

(a)  Antero-posterior  luxations  are  much  more 
common  than  are  lateral  luxations. — Displace- 
ments in  the  antero-posterior  direction  are  more 
common  because  the  movements  of  the  joint  take 
place  in  that  direction,  and  the  width  of  the 
articular  surface  of  the  humerus  from  before  back- 
wards is  comparatively  small.  On  the  other 
hand,  there  is  normally  no  lateral  movement  of 
the  elbow,  and  the  width  of  the  articulation  from 
side  to  side  is  considerable.  The  antero-posterior 
ligaments  are  feeble,  while  the  lateral  ligaments 
are  strong,  and  the  joint,  moreover,  receives  more 
muscular  support  at  its  sides  than  it  does  either 
behind  or  in  front.  The  mutual  support  afforded 
by  the  bones  to  one  another  is  weakened  in  the 
antero-posterior  direction  during  certain  move- 
ments. Thus  in  full  flexion  the  olecranon  has  but 
a  feeble  hold  upon  the  humerus,  while  in  exten- 
sion the  hold  of  the  coronoid  process  upon  that 
bone  is  even  less.  In  a  lateral  direction,  how- 
ever, movement  has  but  a  very  slight  effect  upon 
the  support  the  bones  mutually  derive  from  one 
another. 

(b)  Both  bones  of  the  forearm-  are  m,ore  often 
luxated  together  than  is  either  the  radius  alone 
or  the  ulna  alone. — This  depends  upon  the  power- 
ful ligamentous  connection  between  the  radius 
and  ulna  on  the  one  hand,  and  the  absence  of 
such  connection  between  the  humerus  and  the 
radius  on  the  other.  In  the  dead  subject  it  is  not 
difficult  to  dislocate  the  two  bones  of  the  fore- 
arm, but  it  is  extremely  difficult  to  separate  the 
radius  from  the  ulna  without  great  breaking  and 
tearing  of  parts. 

(c)  The  commonest  dislocation  of  the  two  bones 
together  is   backwards,    the  rarest  is   forwards. — 

s 


274  SURGICAL    APPLIED    ANATOMY      [Part  III 

In  the  former  instance  the  movement  is  resisted  by 
the  small  coronoid  process,  in  the  latter  by  the 
large  and  curved  olecranon.  For  like  reasons  the 
luxation  outwards  is  less  rare  than  is  the  dis- 
placement inwards,  since  the  articular  surface  of 
the  humerus  inclines  downwards  and  inwards  on 
the  inner  side,  and  thus  affords  a  greater  obstacle 
in  that  quarter. 

(d)  If  a  single  bone  be  dislocated  it  will 
usually  be  the  radius. — This  follows  from  the 
absence  of  reliable  union  between  that  bone  and 
the  humerus,  from  the  greater  exposure^  of  the 
radius  ("the  handle  of  the  hand ,;)  to  indirect 
violence,  and  from  its  greater  mobility.  The 
luxation  is  usually  forwards,  due  to  the  fact  that 
the  forms  of  violence  that  tend  most  often  to  dis- 
place the  bone  tend  also  to  draw  it  forwards. 
Paulet  asserts  that  the  posterior  part  of  the 
orbicular  ligament  is  "much  more  resistant  "  than 
is  the  anterior  part.  The  luxation  of  the  ulna 
alone  occurs  in  the  backward  direction,  for  rea- 
sons that  will  be  obvious. 

Dislocations  of  the  elbow  of  all  kinds  may  be 
partial  or  complete.  More  usually  they  are  com- 
plete when  in  the  antero-posterior  direction,  and 
partial  when  the  luxation  is  lateral. 

Some  more  detailed  notice  may  now  be  taken 
of  the  only  two  forms  of  dislocation  at  the  elbow 
that  are  at  all  common. 

(1)  Displacement  of  both  bones  back- 
wards.—  This  may  be  effected  during  forced  ex- 
tension. Here  the  point  of  the  olecranon  pressed 
against  the  humerus  acts  as  the  fulcrum  of  a  lever 
of  the  second  kind,  with  the  result  that  the  sig- 
moid cavity  is  forced  away  from  the  trochlea. 
The  addition  of  violence  to  the  forearm  in  a 
backward  or  upward  direction  would  effect  the 
actual  displacement.  This  condition  may  be  illus- 
trated by  a  fall,  as  in  running,  upon  the  fully 
extended  hand.  The  lesion  may  also  be  produced 
by  certain  violent  wrenchings  of  the  limb.  Mal- 
gaigne   maintained   that  the   particular   kind   of 


Chap.  XIII]       REGION    OF    THE    ELBOW  275 

wrench  most  effectual  in  producing  luxation  was 
a  twisting  inwards  of  the  forearm  while  the 
elbow  was  semi-flexed.  In  this  way  the  internal 
lateral  ligament  was  ruptured,  and  the  coronoid 
process  twisted  inwards  and  downwards  under 
the  humerus,  and  the  bones  thus  displaced  back. 
This  lesion  would  be  difficult  to  effect  while  the 
joint  was  fully  flexed.  In  the  complete  form  the 
coronoid  process  is  opposite  to  the  olecranon 
fossa.  It  can  hardly  occupy  that  hollow  (as  some- 
times described),  since  the  connection  of  the  ulna 
to  the  radius,  and  the  projection  of  the  latter 
bone  behind  the  outer  condyle,  would  prevent  it 
from  actually  falling  into  ■  the  fossa.  The  an- 
terior and  the  two  lateral  ligaments  are  usually 
more  or  less  entirely  torn,  while  the  posterior 
and  the  orbicular  ligaments  escape.  The  biceps  is 
drawn  over  the  lower  end  of  the  humerus,  and  is 
rendered  moderately  tense.  The  brachialis  anti- 
cus  is  much  stretched  and  often  torn.  The  an- 
coneus is  made  very  tense.  Both  the  median  and 
ulnar  nerves  may  be  severely  stretched. 

(2)  Dislocation  of  the  radius  forwards. — 
This  may  be  due  to  direct  violence  to  the  bone 
from  behind,  or  to  extreme  pronation,  or  to  falls 
upon  the  extended  and  pronated  hand.  The  an- 
terior, external,  and  orbicular  ligaments  are  torn. 
There  would  seem  to  be  a  lack  of  evidence  in  sup- 
port of  Hamilton's  statement  that  "  sometimes  the 
anterior  and  external  lateral  are  alone  broken, 
the  orbicular  ligament  being  then  sufficiently 
stretched  to  allow  of  the  complete  dislocation." 
The  biceps  being  relaxed,  the  pronators  act,  and 
the  limb  is  either  pronated  or  assumes  a  position 
midway  between  pronation  and  supination.  Some 
stretching  of  the  supinator  brevis  would  probably 
modify  the  amount  of  pronation.  A  difficulty  in 
the  reduction  is  often  due  to  the  torn  annular 
ligament  coming  between  the  head  of  the  radius 
and  the  humeral  condyle. 

Sprain   of  the   elbow. — Mr.  J.   Hutchinson, 
jun.,    has  shown   that   in   young  children,    under 


276  SUKGICAL    APPLIED    ANATOMY      [Part  III 

five  years,  forcible  traction  of  the  limb  in  the 
supinated  position  may  cause  the  radius  to  slip 
downwards,  away  from  the  orbicular  ligament, 
which  is  displaced  upwards.  In  such  cases  trac- 
tion is  applied  before  the  muscles  of  the  elbow 
have  had  time  to  undergo  their  usual  reflex  con- 
traction, so  that  when  the  child  is  lifted  by  the 
hand  all  the  weight  falls  upon  the  ligaments  at 
the  elbow  instead  of  on  the  muscles.  _  The  only 
ligaments  which  resist  such  a  dislocation  are  (1) 
the  oblique  ulno-radial  ligament,  (2)  the  _  lower 
fibres  of  the  orbicular  ligament  which  grip  the 
head.  Flexion  of  the  elbow  in  the  pronated  posi- 
tion restores  the  ligament  to  its  normal  position. 
It  is  clear  that  this  displacement  is  the  anatomical 
basis  of  the  common  sprain  of  the  elbow  met  with 
in  young  children,  and  usually  due  to  violent 
traction  of  the  hand. 

Fractures  of  the  lower  end  of  the  humerus. 
— These  are  :  (1)  A  fracture  just  above  the  con- 
dyles; (2)  the  "T-shaped  fracture  ';  involving  the 
joint;  (3)  fractures  of  the  internal,  and  (4)  of 
the  external  condyle;  (5)  fracture  of  the  internal 
epicondyle ;  and  (6)  separation  of  the  lower  epi- 
physis. All  these  fractures  are  more  common  in 
the  young. 

(l)  The  fracture  "  at  the  base  of  the  condyles," 
as  it  is  sometimes  called,  is  usually  situate  a  little 
above  the  olecranon  fossa,  where  the  humeral 
shaft  begins  to  expand.  It  is  commonly  trans- 
verse from  side  to  side,  and  oblique  from  behind 
downwards  and  forwards.  It  is  generally  the  re- 
sult of  a  blow  inflicted  upon  the  extremity  of  the 
elbow.  Probably  the  tip  of  the  olecranon  driven 
sharply  against  the  bone  acts  like  the  point  of 
a  wedge,  and  takes  an  important  share  in  the 
production  of  the  fracture.  The  lower  fragment, 
together  with  the  bones  of  the  forearm,  is  gener- 
ally carried  backwards  by  the  triceps,  and  up- 
wards by  that  muscle,  the  biceps,  and  the  brachi- 
alis  anticus.  The  median  or  ulnar  nerves,  especi- 
ally the  latter,  may  be  severely  damaged. 


Chap.  XIII]        REGION    OF    THE    ELBOW  277 

(2)  The  "  T-shaped  fracture  "  is  but  a  variety 
of  the  lesion  just  noted.  In  addition  to  the  trans- 
verse fracture  above  the  condyles,  there  is  also  a 
vertical  fracture  running  between  the  two  con- 
dyles into  the  joint.  The  lower  fragment  is  thus 
divided  into  two  parts.  The  displacement  is  the 
same.  The  fracture  is  very  usually  due  to  a  fall 
upon  the  bent  elbow,  and  here  possibly  also  the  tip 
of  the  olecranon  acts  as  a  wedge,  producing  the 
transverse  fracture,  while  the  prominent  ridge 
along  the  middle  of  the  greater  sigmoid  cavity, 
acting  as  a  second  wedge,  produces  the  vertical 
fracture  into  the  joint. 

(3,  4,  and  5)  For  surgical  purposes  it  is  well 
to  limit  the  term  "  condyle  ,;  to  such  ]oarts  of  the 
extremity  of  the  humerus  as  are  within  the  cap- 
sule, and  the  term  "  epicondyle  '•  to  such  parts 
of  the  lower  projections  of  the  bone  as  are  with- 
out the  joint. 

In  the  so-called  fracture  of  the  inner  condyle 
the  line  of  separation  generally  commences  about 
half  an  inch  above  the  tip  of  the  epicondyle 
(and,  therefore,  outside  the  joint),  and,  running 
obliquely  outwards  through  the  olecranon  and 
coronoid  fossae,  enters  the  articulation  through 
the  centre  of  the  trochlear  surface  (Hamilton). 
The  fragment  is  often  displaced  a  little  upwards, 
backwards,  and  inwards,  the  ulna  going  with  it. 

In  the  fracture  of  the  external  condyle  the  line 
commences  also  above  the  epicondyle  and  outside 
the  joint,  and,  running  downwards,  enters  the 
joint  usually  between  the  trochlear  surface  and 
the  surface  for  the  radius.  The  displacement  is 
trifling  and  inconstant. 

On  account  of  its  insignificant  size,  a  fracture 
of  the  external  epicondyle  is  scarcely  possible. 
Fractures  of  the  inner  epicondyle  are,  however, 
quite  common,  the  joint  remaining  f ree  (Fig.  47). 
This  epicondyle  exists  as  a  distinct  epiphysis, 
which  unites  at  the  age  of  eighteen,  and  which  at 
any  time  before  that  age  may  be  separated  from 
the  bone  by  direct  injury  or  muscular  violence. 


278 


SUEGtCAL   APPLIED   ANATOMY      [Part  til 


Owing  to  the  dense  aponeurotic  fibres  that  cover 
the  part,  much  displacement  of  the  fragment  is 
uncommon.  When  displacement  exists,  it  is  in 
the  general  line  of  the  common  flexor  muscles  that 
arise  from  the  tip  of  the  process.  In  such  cases 
the  ulnar  nerve,  which  lies  behind  the  process,  is 
often   damaged. 

6.  The  lower  epiphysis  (Fig.  47).— In  the  car- 
tilaginous lower  extrem- 
ity of  the  humerus,  four 
ossific  centres  appear, 
one  for  each  of  the  fol- 
lowing parts  :  capitel- 
lum,  trochlea,  internal 
and  external  epicon- 
dyles.  The  three  centres 
named  first  unite  to  form 
the  main  epiphysis,  that 
for  the  internal  epicon- 
dyle  remaining  separate 
(Fig.  47).  The  epiphy- 
seal line  is  thus  divided 
into  two  parts,  and  is 
irregular  in  form ;  it  lies 
both  within  and  without 
the  capsule  of  the  joint 
(Fig.  47);  Its  position 
may  be  indicated  by  a 
line  drawn  from  the 
upper  border  of  the  ex- 
ternal to  the  lower  border 
of  the  internal  epicon- 
dyle.  The  lower  epiphysis  joins  the  shaft  at 
seventeen.  Thus,  after  the  age  of  seventeen  the 
growth  of  the  bone  must  depend  upon  the  activity 
of  the  upper  epiphysis,  which  does  not  unite  until 
twenty.  Excision  of  the  elbow,  therefore,  after 
the  sixteenth  or  seventeenth  year,  will  not  be  fol- 
lowed by  arrest  of  development  in  the  limb,  even 
if  the  epiphyseal  line  has  been  transgressed  by 
the  saw.  Several  cases  are,  however,  reported  of 
marked   arrest  of  growth   in   the   limb   following 


Fig.  47. — Lower  epiphysis  of  the 
humerus  from  behind. 

A,  Centre  for  internal  epicondyle ;  b,c,d, 
united  centres  for  the  trochlea, 
capitellura,  and  external  epicon- 
dyle ;  e,  b,  epiphyseal  line ;  the 
capsular  attachment  is  indicated 
by  red  lines. 


Chap.  XIII]        REGION    OF    THE    ELBOW  279 

upon  injuries  to  the  lower  epiphysis  before  the 
sixteenth  year,  and  to  the  upper  epiphysis  before 
twenty.  Since  the  greater  part  of  the  epiphyseal 
line  is  within  the  capsule,  it  follows  that  but 
little  displacement,  other  than  a  slight  movement 
backwards,  is  consequent  upon  the  separation  of 
the  mass. 

Fractures  of  the  olecranon  are  commonly 
due  to  direct  violence,  and  in  a  few  cases  to  severe 
indirect  violence  applied  to  the  lower  end  of  the 
humerus  or  upper  end  of  the  ulna.  Instances  of 
fracture  by  muscular  action  are  few,  and  open 
to  some  question.  The  fracture  is  most  commonly 
met  with  about  the  middle  of  the  process,  just 
where  it  begins  to  be  constricted,  and  is  usually 
transverse  in  direction.  The  amount  of  displace- 
ment effected  by  the  triceps  varies,  and  depends 
upon  the  extent  to  which  the  dense  periosteum 
about  the  process  and  the  ligaments  that  are 
attached  to  it  are  torn.  The  olecranon  is  de- 
veloped mainly  from  the  shaft  of  the  ulna  (Fig. 
46).  There  is  a  scale-like  epiphysis,  however,  at 
the  summit  of  the  process  which  joins  the  rest  of 
the  olecranon  at  the  age  of  seventeen.  Occasion- 
ally another  epiphyseal  centre  occurs,  giving 
origin  to  the  upper  third  of  the  olecranon  (Fig. 
46).  In  young  subjects  the  scale-like  epiphysis 
may  be  separated  by  violence,  or  the  cartilagin- 
ous olecranon  may  be  dissevered  from  the  rest  of 
the  bone.  The  common  fracture  of  the  adult 
olecranon  does  not  follow  the  epiphyseal  line. 

Fracture  of  the  coronoid  process  is  an 
extremely  rare  accident.  It  is  impossible  to 
understand  how  the  process  can  be  torn  off  by  the 
action  of  the  brachialis  anticus,  as  some  main- 
tain, since  that  muscle  is  inserted  rather  into  the 
ulna  at  the  base  of  the  projection  than  into  the 
process  itself  (Fig.  46).  Nor  can  it  be  separated 
as  an  epiphysis,  as  supposed  by  others,  since  it 
does  not  exist  as  such. 

Fractures  of  the  head  or  neck  of  the  radius 
are   rare,   and  occur   usually  with   dislocation  or 


280  SUEGICAL    APPLIED    ANATOMY       [Part  III 

other  severe  injury.  The  head  is  commonly  found 
split  or  starred,  and  the  lesion,  if  limited  to  the 
head,  could  hardly  be  diagnosed.  The  upper 
epiphysis  of  the  radius  is  entirely  within  the 
limits  of  the  annular  ligament,  and  could  scarcely 
be  separated  in  a  simple  lesion.  It  is  a  mere  disc 
of  cartilage  joining  the  shaft  at  the  age  of  seven- 
teen. When  the  neck  is  broken  the  upper  end  of 
the  lower  fragment  is  drawn  well  forwards  by 
the  biceps  muscle. 

Resection  of  the  elbow  may  be  performed  in 
many  ways.  In  all  procedures  there  is  danger  of 
injuring  the  ulnar  nerve,  and  some  little  difficulty 
often  in  clearing  the  prominent  internal  condyle. 
If  the  knife  be  kept  close  to  the  bone,  no  vessel  of 
any  magnitude  should  be  divided.  The  muscles 
most  disturbed  are  the  triceps,  anconeus,  supin- 
ator brevis,  extensor  carpi  ulnaris,  extensor  carpi 
radialis  brevior,  and  brachialis  anticus.  It  is 
most  important  to  preserve  the  periosteum  over 
the  olecranon,  so  that  the  triceps  may  still  have 
some  attachments  to  the  forearm.  Jt  is  never 
necessary  to  divide  the  insertion  of  the  brachialis 
anticus,  still  less  of  the  biceps,  although  some 
few  fibres  of  the  former  muscle  may  be  separated 
in  removing  the  upper  surface  of  the  ulna.  By 
the  subperiosteal  method  the  periosteum  is  care- 
fully peeled  off  from  all  the  parts  to  be  resected, 
and  is  preserved.  By  this  means  the  triceps  re- 
tains a  hold  upon  the  ulna,  and  the  restoration 
of  the  joint  is  more  complete.  The  functions  of 
the  joint  may  be  well  restored  after  resection, 
especially  when  performed  by  the  subperiosteal 
method,  but  it  would  appear  that  after  no  method 
are  the  anatomical  details  of  the  joint  repro- 
duced. Thus,  in  a  successful  case,  the  new  joint 
will  assume  the  bimalleolar  form,  and  will  re- 
semble the  ankle-  rather  than  the  elbow-joint.  The 
humerus  throws  out  two  malleoli  on  the  sites  of 
the  normal  condyles,  and  in  the  concavity  between 
them  the  ulna  and  radius  are  received.  Between 
the  ulna  and  the  humerus  new  ligaments  form, 


Chap.  XIII]         REGION    OF    THE    ELBOW  281 

and  a  new  annular  ligament  for  the  radius  is  also 
developed. 

Position  ol  the  main  nerves  at  the  elbow. 

— The  musculo-spiral  is  found  in  front  of  the 
external  epicondyle,  under  cover  of  the  supinator 
longus,  where  it  divides  into  posterior  interos- 
seus  and  radial.  The  median  is  situated  at  the 
inner  border  of  the  brachial  artery;  the  ulnar  lies 
in  a  groove  behind  the  internal  epicondyle. 


CHAPTER    XIV 

THE      FOREARM 

Surface  anatomy.  —  At  its  upper  half,  and 
especially  in  its  upper  third,  the  limb  is  much 
wider  in  its  transverse  than  in  its  antero-posterior 
diameter.  A  horizontal  section  through  this  part 
will  show  a  cut  surface  that  is  somewhat  oval 
in  outline,  and  is  at  the  same  time  flattened  in 
front  and  more  convex  behind.  This  outline  is 
best  seen  in  muscular  subjects,  and  depends  chiefly 
upon  the  development  of  the  lateral  masses  of 
muscle  that  descend  from  the  condyles.  In  the 
non-muscular,  the  limb,  even  in  its  highest  parts, 
tends  to  assume  a  rounded  rather  than  an  oval 
outline.  In  women  and  children,  also,  the  limb 
is  round,  owing  to  the  comparatively  slight  de- 
velopment of  the  lateral  muscular  masses,  and  to 
the  accumulation  of  fat  on  the  front  and  back  of 
the  limb.  The  posterior  surface  of  the  forearm 
in  a  vigorous  subject  presents  along  its  outer 
border  a  prominence  formed  by  the  supinator 
longus  and  the  two  radial  extensors,  which  become 
tendinous  below  the  centre  of  that  border.  On 
the  lower  third  of  this  edge  is  a  slight  eminence, 
directed  obliquely  downwards,  outwards,  and  for- 
wards, and  due  to  the  crossing  of  the  extensors 
of  the  thumb.  In  the  middle  of  the  posterior 
surface  is  another  elevation,  running  down  from 
the  outer  condyle,  and  formed  mainly  by  the 
extensor  communis.  To  the  inner  side  of  this 
eminence  is  a  groove,  well  seen  in  the  very  mus- 

282 


Chap.  XIV]  THE  FOREABM  283 

cular,  that  indicates  the  posterior  border  of  the 
ulna.  The  ulna  is  subcutaneous  throughout  its 
entire  extent,  and  can  be  readily  examined.  The 
upper  half  of  the  radius  is  too  deeply  placed  to 
be  well  made  out,  but  the  lower  half  of  the  bone 
can  be  easily  felt  beneath  the  skin.  The  course  of 
the  radial  artery  is  represented  by  a  line  drawn 
from  the  outer  border  of  the  biceps  tendon  at  the 
bend  of  the  elbow  to  a  point  in  front  of  the  styloid 
process  of  the  radius.  The  pulse  is  felt  between 
the  styloid  process  and  tendon  of  the  flexor  carpi 
radialis  where  the  artery  rests  on  the  lower  ex- 
tremity of  the  radius.  The  middle  and  lower 
thirds  of  the  ulnar  artery  follow  a  line  from 
the  inner  condyle  to  the  radial  side  of  the  pisi- 
form bone.  The  upper  third  would  be  repre- 
sented by  a  line  drawn  from  the  middle  of  the 
bend  of  the  elbow  to  meet  the  first  line  at  the 
junction  of  the  upper  and  middle  thirds  of  the 
inner  border  of  the  forearm.  Such  a  line  would 
be  slightly  curved,  with  its  concavity  outwards. 
The  tendons,  etc.,  that  can  be  demonstrated  at  the 
lower  extremity  of  the  forearm  will  be  considered 
in  the  description  of  the  wrist. 

Vessels. —  It  is  well  to  note  the  very  free  anas- 
tomoses that  exist  along  the  greater  part  of  the 
limb  between  the  ulnar  and  radial  arteries.  This 
fact  was  illustrated  by  a  case  under  my  care,  some 
time  ago,  in  the  London  Hospital.  A  seaman 
had  inflicted  upon  his  left  forearm  three  deep 
transverse  wounds  across  the  front  of  the  limb 
with  a  sharp  knife.  The  wounds  were  about 
1^  inch  apart.  The  radial  artery  was  divided  in 
each  of  the  wounds,  and  that  vessel,  therefore, 
presented  six  cut  ends.  It  would  appear  to  be 
sufficient  to  ligature  the  proximal  and  distal  ends 
of  the  wounded  vessel,  and  to  leave  the  two  iso- 
lated portions  of  the  artery,  each  about  1^  inch 
in  length,  alone.  I  applied  ligatures  to  five  of 
the  divided  ends,  leaving  the  lower  end  of  tho 
upper  isolated  piece  of  the  artery  untied,  and 
watched  the  effect.     During  the  course  of  the  day, 


284  SURGICAL   APPLIED   ANATOMY      [Part  III 

when  the  man  had  rallied  from  the  profound 
faintness  due  to  the  great  loss  of  blood  he  had 
experienced,  copious  bleeding  took  place  from  this 
single  unsecured  end  of  the  vessel,  and  it,  of 
course,  had  also  to  be  tied. 

There  is  a  singular  absence  of  large  blood- 
vessels or  nerves  along  the  posterior  aspect  of  the 
forearm,  and  it  is  significant  that  this  is  the 
aspect  of  the  limb  most  exposed  to  injury.  For  a 
hand's-breadth  below  the  olecranon  there  is  almost 
an  entire  absence  of  superficial  veins. 

The  median  nerve  passes  between  the  two 
heads  of  the  pronator  teres,  and  may  possibly  be 
compressed  by  that  muscle  when  in  vigorous 
action.  At  the  wrist  the  median  is  between  the 
tendons  of  the  flexor  carpi  radialis  and  flexor 
sublimis  digitorum;  it  lies  deep  to  the  tendon 
of  the  palmaris  longus,  which  serves  as  a  useful 
guide  to  its  position. 

The  bones  of  the  forearm. — Transverse  sec- 
tions of  the  limb  at  various  levels  show  that  the 
radius  and  ulna  are  in  all  parts  nearer  to  the 
posterior  than  the  anterior  aspect  of  the  ex- 
tremity (Figs.  48  and  49).  This  relation  is  the 
more  marked  the  higher  up  the  section.  The  two 
bones  are  nearest  to  the  centre  of  the  limb  about 
the  lower  end  of  the  middle  third.  At  the  upper 
part  of  the  forearm  the  muscles  are  found  mainly 
at  the  sides  and  in  front.  The  lower  the  section 
proceeds  down  the  limb,  the  less  will  the  bones  be 
covered  at  the  sides,  and  the  more  equally  will 
the  soft  parts  be  found  distributed  about  the 
anterior  and  posterior  aspects  of  the  limb.  It 
will  be  noticed  that  where  one  bone  is  the  more 
substantial  the  other  is  the  more  slender,  as  near 
the  elbow  and  wrist;  and  that  it  is  about  the 
centre  of  the  limb  that  the  two  are  most  nearly  of 
equal  strength.  The  proximity  of  the  two  bones, 
and  especially  of  the  ulna,  to  the  posterior  aspect 
of  the  limb  permits  them  to  be  easily  examined 
from  that  surface,  while  it  is  from  the  same  aspect 
that    resections     and    other    operations    upon    the 


Chap.  XIV] 


THE  FOEEAEM 


285 


bones  are  most  readily  performed.  It  will  be 
understood,  moreover,  that  in  compound  frac- 
tures, due  to  penetration  of  fragments,  the  wound 
is  more  usually  on  the  posterior  aspect  of  the 
limb. 

The   important  movements   of   pronation   and 
supination  take   place   between   these   bones,    and 
round  an  axis  cor- 
responding    to     a 
line  drawn 

through  the  head 
of  the  radius,  the 
lower  end  of  the 
ulna,  and  the 
metacarpal  bone 
of  the  ring-finger. 
In  extreme  pro- 
nation the  radius 
crosses  the  ulna 
obliquely  ;  the  two 
bones  are  almost 
in  contact  at  the 
point  of  crossing ; 
the  lower  fibres 
of  the  inter osseus 
membrane  and  the 
posterior  radio- 
ulnar ligament 
are  tight.  #  "The 
chief  influ- 
ence  in  check- 
ing supination  is 
not  _  to  be  found 
in  ligament  at  all,  but  in  the  contact  of  the  pos- 
terior edge  of  the  sigmoid  cavity  of  the  radius 
with  the  tendon  of  the  extensor  carpi  ulnaris, 
as  it  lies  in  the  groove  between  the  styloid  pro- 
cess and  the  round  head  of  the  ulna  "  (H.  Mor- 
ris). Of  the  two  movements,  supination  is  the 
more  powerful.  This  is  illustrated  in  many  ways. 
In  using  a  screw-driver  or  a  gimlet  the  movements 
of   pronation    and   supination   are   conspicuously 


n        o 

Fig.  48.— A  transverse  section  through  the 
middle  of  the  forearm.    {Branny) 

a,  Radius ;  &,  ulna ;  c,  supinator  longus  ;  d,  flexor 
longus  pollicis  ;  e,  flexor  carpi  radialis  ;  /, 
palinaris  longus  ;  g,  flexor  sublimis  digi- 
torum ;  li,  flexor  carpi  ulnaris ;  i,  flexor 
profundis  digitoruiu  ;  k,  extensor  carpi 
ulnaris  ;  I,  extensor  indicis  ;  m,  extensor 
minimi  digit! ;  n,  extensor  communis  digi- 
torum  ;  o,  extensor  ossis  and  extensor 
secundi  internodii  pollicis ;  q,  extensor 
carpi  radialis  brevior ;  r  extensor  carpi 
radialis  longior ;  s,  pronator  radii  teres  ; 
1,  radial  vessels  and  nerve  ;  2,  ulnar  vessels 
and  nerve. 


286  SURGICAL    APPLIED    ANATOMY      [Part  III 

involved,  but  the  main  force  is  applied  during 
supination.  It  is  significant  that  the  thread  of 
a  corkscrew  is  so  turned  that  it  shall  be  inserted 
by  supination  rather  than  by  pronation. 

The  only  position  in  which  the  two  bones  are 
parallel  to  one  another  is  the  mid-position  be- 
tween pronation  and  supination.  It  is  in  this 
posture  only  that  the  interosseous  membrane  is 
uncoiled  throughout.  Hence  the  selection  of  this 
position  in  the  adjustment  of  most  fractures  of 
the  forearm.  The  interosseous  space  is  an  ir- 
regular ellipse,  a  little  larger  below  than  above. 
It  is  narrowest  in  full  pronation,  widest  in 
supination,  and  nearly  as  wide  in  the  mid- 
position. 

It  may  be  noted  that  the  oblique  ligament  tends 
to  resist  forces  that  would  drag  the  radius  away 
from  the  humerus,  and  takes  the  place  and  the 
function  of  a  direct  ligament,  passing  from  the 
humerus  to  the  radius,  while  the  interosseous 
membrane,  from  the  obliquity  of  its  fibres,  makes 
the  ulna  take  a  share  in  the  strain  put  upon  the 
radius  when  that  bone  is  forced  upwards,  as  in 
resting  on,  or  pushing  with,  the  palm. 

Fractures  of  the  forearm. — The  two  bones 
are  more  often  broken  together  than  is  either  the 
radius  or  the  ulna  alone.  The  radius,  when 
broken  alone,  is  usually  fractured  by  indirect 
violence,  since  it^  receives  more  or  less  entirely 
all  shocks  transmitted  from  the  hand.  The  ulna, 
on  the  contrary,  is  more  often  broken  by  direct 
violence,  it  being  the  more  superficial  and  exposed 
of  the  two  bones.  For  example,  in  raising  the 
arm  to  ward  off  a  blow  from  the  head,  the  ulna 
becomes  uppermost.  When  the  two  bones  are 
broken  together,  the  violence  may  be  direct  or 
indirect.  Malgaigne  reports  a  case  where  both 
bones  were  broken  by  muscular  violence  in  a 
patient  while  shovelling  earth.  Here  the  bones 
probably  were  broken  between  the  two  opposed 
forces  represented  by  the  biceps  and  brachialis  an- 
ticus  above  and  the  weight  of  the  loaded  shovel  in 


Chap.  XIV]  THE  FOREARM  287 

the  hand  below.  When  both  bones  are  broken 
and  the  fractures  are  oblique,  shortening  may  be 
produced  by  the  united  action  of  the  flexors  and 
extensors.  The  displacement  varies  greatly,  and 
depends  rather  upon  the  direction  of  the  violence 
than  upon  muscular  action.  Thus  Hamilton 
says  :  "  I  have  seen  the  fragments  deviate  slightly 
in' almost  every  direction."  If  union  be  delayed, 
the  delay  is  usually  in  the  radius,  since  it  is  the 
more  mobile  of  the  bones. 

When  the  radius  alone  is  broken  (1)  between 
the  insertions  of  the  biceps  and  pronator  teres, 
the  upper  fragment  is  flexed  by  the  biceps  and 
fully  supinated  by  that  muscle  and  the  small 
supinator.  The  lower  fragment  will  be  pronated 
by  the  two  pronators,  and  drawn  in  towards 
the  ulna  by  means  of  those  muscles.  If  such 
a  fracture  be  put  up  with  the  hand  midway 
between  the  prone  and  supine  positions,  the 
following  evils  result :  the  upper  fragment  is 
fully  supinated  by  the  muscles;  the  lower  frag- 
ment is  placed  in  the  mid-position  by  the  splints. 
It  follows  that  the  proper  axis  of  the  bone 
is  not  reproduced,  and  the  use  of  the  biceps 
and  supinator  brevis  as  supinators  is  entirely 
lost.  Thus  patients  so  treated  usually  recover 
with  great  loss  in  the  power  of  supination ;  and 
to  avoid  this  ill  result,  ^  it  is  advised  to  put  the 
limb  up  in  full  supination,  so  that  the  two  frag- 
ments may  unite  in  their  proper  axis,  the  upper 
fragment  being  supinated  by  the  muscles,  the 
lower  by  the  splints.  (2)  When  the  fracture  is 
between  the  insertions  of  the  two  pronators,  the 
upper  fragment  may  be  carried  a  little  forwards 
by  the  biceps  and  pronator  teres,  and  drawn  to- 
wards the  ulna  by  the  latter  muscle.  The  lower 
fragment  will  be  adducted  to  the  ulna  by  the 
pronator  quadratus,  and  its  upper  end  will  be 
still  further  tilted  towards  that  bone  by  the 
action  of  the  supinator  longus  upon  the  styloid 
process. 

When  the  ulna  alone  is  broken,  as,  for  example, 


288  SURGICAL    APPLIED    ANATOMY      [Part  III 

about  its  middle,  the  upper  fragment  may  be 
drawn  a  little  forwards  by  the  brachialis  anticus, 
while  the  lower  fragment  will  be  carried  towards 
the  radius  by  the  pronator  quadratus. 

The  displacement,  however,  in  all  cases^  is  in- 
fluenced as  much  by  the  direction  of  the  violence 
as  by  the  action  of  muscles.  When  the  fragments, 
after  fracture  of  one  or  of  both  bones,  fall  in 
towards  one  another,  so  as  to  meet  across  the 
interosseous  space,  attempts  are  sometimes  made 
to  separate  the  broken  ends  and  to  preserve  the 
integrity  of  the  space  by  the  use  of  graduated 
pads.  These  pads,  however,  if  supplied  with 
sufficient  force  to  separate  the  fragments,  will 
probably  compress  one  or  both  of  the  arteries  of 
the  limb,  and  cause  great  distress,  resulting  in  a 
peculiar  form  of  paralysis,  due,  it  is  believed, 
to  the  compression  shutting  off  the  blood-supply 
to  the  muscles.  Subsequently  the  muscles  undergo 
contracture. 

The  fact  that  the  bulk  of  the  venous  blood  of 
the  forearm  is  returned  by  surface  veins  may 
explain  the  ready  occurrence  of  severe  oedema  in 
the  limb  when  fractures  are  treated  with  impro- 
perly applied  splints  or  bandages.  Since  the 
arteries  also  can  be  readily  affected  by  pressure, 
it  follows  that  gangrene  of  the  limb,  as  a  result 
of  improper  treatment,  is  more  common  after 
fracture  of  the  forearm  than  after  fracture  in 
any  other  part. 

Amputation  of  the  forearm. — In  amputa- 
tion of  the  forearm  by  double  transfixion  flaps, 
at  about  the  upper  part  of  the  middle  third  the 
parts  would  be  cut  in  the  following  manner  (Fig. 
48)  :  On  the  face  of  the  anterior  flap  would  be 
seen  from  without  inwards  the  supinator  longus 
(cut  the  whole  length  of  the  flap),  then  the  flexor 
sublimis  (cut  to  a  like  extent),  and,  lastly,  the 
flexor  carpi  ulnaris.  Between  the  supinator 
longus  and  the  flexor  sublimis  the  divided  end  of 
the  pronator  teres  isseen;  andbetween  the  flexor 
sublimis  and  the  skin  would  lie  the  flexor  carpi 


Chap.  XIV] 


THE    FOEEARM 


289 


radialis  and  the  palmaris  longus.  t  The  latter 
would  appear  as  a  tendon  at  the  inner  border 
of  the  flap.  In  the  angle  between  the  two  flaps 
would  be  found  in  front  of  the  radius  a  little  of 
the  flexor  longus  pollicis,  and  in  front  of  the 
ulna,  the  flexor  profundus,  the  latter  cut  much 
the  longer.  Quite  close  to  the  radius,  and  for 
the  most  part  behind  it,  would  be  the  lowest 
part  of  the  small  supinator,  while  behind  the  ulna 
would  be  the  cut  fibres  of  the  upper  end  of  the  ex- 
tensor ossis.  On  the  face  of  the  posterior  flap  would 
be  seen  from  without  inwards  the  extensor  carpi 
radialis  longior  and  brevior,  the  extensor  com- 
munis, the  extensor  of  the  little  finger,  and  the 
extensor  carpi  ulnaris.  The  radial  artery  will 
run  the  whole  length 
of  the  anterior  flap, 
and  be  cut  near  its 
outer  border  to  the 
inner  side  of  the  supin- 
ator longus.  The  ulnar 
artery  will  be  cut 
shorter,  in  front  of  the 
bone,  and  between  the 
flexor  sublimis  and 
flexor  profundus.  The 
anterior  interosseous 
vessels  will  be  divided 
immediately  in  front  of 
the  interosseous  mem- 
brane. The  posterior 
interosseous  vessels  will 
be  cut  long,  and  will 
be  found  between  the 
superficial  and  deep 
muscles. 

Fig.  49  shows  the 
relation  of  the  parts  as 
they  would  be  cut  in 
a  circular  amputation 
of  the  limb  through  the  lower  third. 


Jl   o 


Fig.  49.  —  A  transverse  section 
through  the  lower  third  of  the 
lor  ear  in .     (B  raune. ) 

«,  Radius  ;  b,  ulna;  c,  supinator  longus; 
cl,  flexor  longus  pollicis ;  e,  flexor 
carpi  radialis  ;  /,  palmaris  longus  ; 
g,  flexor  sublimis  digitorum  ;  h, 
flexor  carpi  ulnaris ;  i,  flexor  pro- 
fundus digitorum  ;  j,  pronator  quad- 
ratus  ;   k,   extensor   carpi  ulnaris ; 

1,  extensor  indicia  ;  to,  extensor 
minimi  digiti ;  n,  extensor  com- 
munis digitorum  ;  o,  extensor  se- 
cundi  internodii  pollicis ;  p,  exten- 
sor primi  internodii  pollicis  ;  q, 
extensor  carpi  radialis  brevior  ;  r, 
extensor  carpi  radialis  longior,  with, 
in  front  of  it,  the  extensor  ossis 
metacarpi  pollicis  ;  1,  radial  vessels  ; 

2,  ulnar  vessels  ;  3,  median  nerve. 


CHAPTER   XV 

THE  WRIST  AND  HAND 

Surface  anatomy. — The  following  structures 
can  be  made  out  about  the  wrist :  Commencing 
at  the  outer  side,  the  lower  extremity  and  styloid 
process  of  the  radius  can  be  well  denned.  The 
bone  is  here  superficial  in  front  and  behind.  The 
styloid  process  lies  more  anteriorly  than  does  the 
corresponding  process  of  the  ulna,  and  also  de- 
scends about  \  an  inch  lower  down  the  limb. 
The  outer  surface  of  the  radius  at  the  wrist  is 
crossed  by  the  tendons  of  the  extensor  ossis  meta- 
carpi  and  extensor  brevispollicis.  These  are  very 
distinct  when  the  thumb  is  abducted,  and  the  slit- 
like interval  between  the  two  can  be  felt.  About 
the  centre  of  the  front  of  the  wrist  is  the  pal- 
maris  longus  tendon,  which  is  usually  the  most 
conspicuous  of  the  tendons  on  this  aspect  of 
the  joint.  It  will  be  found  absent  in  quite  10  per 
cent,  of  wrists  examined.  It  is  rendered  most 
prominent  when  the  wrist  is  a  little  flexed,  the 
fingers  and  thumbs  extended,  and  the  thenar  and 
hypothenar  eminences  as  much  approximated  as 
possible.  A  little  to  its  outer  side  is  the  larger  but 
less  prominent  tendon  of  the  flexor  carpi  radialis. 
In  the  narrow  groove  between  these  two  tendons 
lies  the  median  nerve,  and  on  the  radial  side  of 
the   flexor   carpi    radialis   is   the   radial    artery.* 

*  Sometimes  the  superficialis  vohe  arises  higher  and  is  larger  than 
usual.  It  then  runs  by  the  side  of  the  radial  in  front  of  the  wrist,  and, 
giving  additional  volume  to  the  pulse,  has  been  the  foundation  of  the 
so-called  "double  pulse." 

290 


Chap.  XVJ         THE    WRIST    AND    HAND  291 

The  venae  comites  surround  the  artery,  and  when 
distended  alter  the  character  of  the  pulse  (Hill). 
Towards  the  inner  border  of  the  wrist  the  flexor 
carpi  ulnaris  tendon  is  evident,  descending  to 
the  pisiform  bone.  It  is  rendered  most  distinct 
when  the  wrist  is  slightly  flexed  and  the  little 
finger  pressed  forcibly  into  the  palm.  In  the 
hollow  which  this  posture  produces  between  the 
last-named  tendon  and  the  palmaris  longus  lie 
the  flexor  sublimis  tendons,  and  just  to  the  radial 
side  of  the  flexor  carpi  ulnaris  the  pulsations  of 
the  ulnar  artery  can  be  felt.  Beneath  the  thin 
skin  in  front  of  the  wrist  a  part  of  the  plexus  of 
veins  can  be  seen  that  end  in  the  median  and 
anterior  ulnar  trunks.  The  ulnar  nerve  grooves 
the  radial  side  of  the  pisiform  bone. 

At  the  back  of  the  wrist  the  following  tendons 
can  be  readily  distinguished  from  without  in- 
wards :  the  extensor  longus  pollicis  (extensor 
secundi  internodii),  the  extensor  communis,  and 
the  extensor  carpi  ulnaris.  Of  these,  the  most 
prominent  is  the  first-named.  It  is  rendered 
most  distinct  when  the  thumb  is  forcibly  abducted 
and  extended.  The  tendon  leads  up  to  a  small 
but  prominent  bony  elevation  on  the  back  of 
the  radius  that  marks  the  outer  border  of  the 
osseous  groove  for  its  reception.  This  tendon, 
when  it  reaches  the  radius,  points  to  the  centre 
of  the  posterior  surface  of  that  bone,  and  also 
indicates  roughly  the  position  of  the  interval 
between  the  scaphoid  and  semilunar  bones.  The 
lower  end  of  the  ulna  is  very  distinct.  When  the 
hand  is  supine,  its  styloid  process  is  exposed  at 
the  inner  and  posterior  aspect  of  the  wrist  to  the 
inner  side  of  the  extensor  carpi  ulnaris.  In 
pronation,  however,  the  process  is  rendered  less 
distinct,  while  the  head  projects  prominently  on 
the  posterior  part  of  the  wrist,  and  is  found  to  lie 
between  the  tendons  of  the  extensor  carpi  ulnaris 
and  extensor  minimi  digiti. 

The  ivrist-joint.—-r]Lhe  tip  of  the  styloid  pro- 
cess of  the  ulna  corresponds  to  the   line  of  the 


292  SURGICAL    APPLIED    ANATOMY      [Part  III 

wrist-joint,  and  a  knife  entered  below  that  point 
would  enter  the  articulation.  A  knife  entered 
horizontally  just  below  the  tip  of  the  styloid  pro- 
cess of  the  radius  would  hit  the  scaphoid  bone. 
A  line  drawn  between  the  two  styloid  processes 
would  slope  downwards  and  outwards,  its  two 
extremities  would  represent  the  extreme  inferior 
limits  of  the  radio-carpal  joint,  and  would  fairly 
correspond  to  the  chord  of  the  arc  formed  by  the 
line  of  that  joint.  The  line  between  the  styloid 
processes  would  be  nearly  \  an  inch  below  the 
summit  of  the  arch  of  the  wrist- joint. 

There  are  several  folds  in  the  skin  on  the  front 
of  the  wrist;  of  these,  the  lowest  is  the  most  dis- 
tinct. It  is  a  little  convex  downwards,  precisely 
crosses  the  neck  of  the  os  magnum  in  the  line  of 
the  third  metacarpal  bone  (Tillaux),  and  is  not 
quite  |  of  an  inch  below  the  arch  of  the  wrist 
joint.  It  is  about  \  an  inch  above  the  carpo- 
metacarpal joint,  and  indicates  very  fairly  the 
upper  border  of  the  anterior  annular  ligament 
(Fig.  53). 

The  palmar  surface  of  hand. — The  palm  is  con- 
cave in  the  centre  where  the  skin  is  adherent  to 
the  palmar  fascia.  This  "  hollow  of  the  hand  ;'  is 
of  somewhat  triangular  outline,  with  the  apex  up- 
wards. On  either  side  are  the  thenar  and  hypo- 
thenar  eminences.  At  the  upper  end  of  the  former 
eminence,  a  bony  projection  is  felt,  just  below  and 
internally  to  the  radial  styloid  process,  which  is 
formed  by  the  tubercle  of  the  scaphoid  and  ridge 
on  the  trapezium  (Fig.  53).  The  interval  separat- 
ing these  two  processes  of  bone  cannot  always  be 
made  out.  At  the  upper  extremity  of  the  hypo- 
thenar  eminence  is  the  projection  of  the  pisiform 
bone,  and  just  below  it  the  unciform  process  can 
be  identified.  Below  the  hollow  of  the  palm,  and 
opposite  the  clefts  between  the  four  fingers,  three 
little  elevations  are  seen,  especially  when  the  first 
phalanges  are  extended,  and  the  second  and  third 
are  flexed.  These  correspond  to  the  fatty  tissue 
between  the  flexor  tendons  and  the  digital  slips 


Chap.  XV]        THE    WRIST    AND    HAND  293 

of  the  palmar  fascia.  The  grooves  that  may  be 
seen  to  separate  the  elevations  correspond  to  those 
slips. 


Fig.  50. -Surface  markings  on  the  palm  of  the  hand. 
The  thick  black  lines  "represent  the  chief  creases  on  the  skin. 

Of  the  creases  in  the  skin  of  the  palm  (Fig.  50) 
three  require  especial  notice.  The  first  starts  at 
the    wrist,    between    the    thenar    and    hypothenar 


294  SURGICAL   APPLIED   ANATOMY  [Part  III 

eminences,  and,  marking  off  the  former  eminence 
from  the  palm,  ends  at  the  outer  border  of  the 
hand  at  the  base  of  the  index  finger.  The  second 
fold  is  slightly  marked.  It  starts  from  the  outer 
border  of  the  hand,  where  the  first  fold  ends. 
It  runs  obliquely  inwards  across  the  palm  with 
a  marked  inclination  towards  the  wrist,  and  ends 
at  the  outer  limit  of  the  hypothenar  eminence. 
The  third,  lowest,  and  best-marked  of  the  folds 
starts  from  the  little  elevation  opposite  the  cleft 
between  the  index  and  middle  fingers,  and  runs 
nearly  transversely  to  the  ulnar  border  of  the 
hand,  crossing  the  hypothenar  eminence  at  the 
upper  end  of  its  lower  fourth.  An  unimportant 
crease  running  obliquely  from  the  third  to  the 
second  fold  gives  to  these  markings  the  outline 
of  the  letter  M.  The  first  fold  is  produced  by  the 
opposition  of  the  thumb,  the  second  mainly  by 
the  bending  simultaneously  of  the  metacarpo- 
phalangeal joints  of  the  first  and  second  fingers, 
and  the  third  by  the  flexion  of  the  three  inner 
fingers.  The  second  fold,  as  it  crosses  the  third 
metacarpal  bone,  corresponds  approximately  to  the 
lowest  point  of  the  superficial  palmar  arch  (Fig.  50). 
The  third  fold  crosses  the  necks  of  the  metacarpal 
bones,  and  indicates  pretty  nearly  the  upper  limits 
of  the  synovial  sheaths  for  the  flexor  tendons  of  the 
three  outer  fingers  (Fig.  53).  A  little  way  below 
this  fold  the  palmar  fascia  breaks  up  into  its  four 
slips,  and  midway  between  the  fold  and  the  webs 
of  the  fingers  lie  the  metacarpo-phalangeal  joints. 
Of  the  transverse  folds  across  the  fronts  of  the 
fingers  corresponding  to  the  metacarpo-phalangeal 
and  phalangeal  joints,  the  highest  is  single  for 
the  index  and  little  finger  and  double  for  the 
other  two.  It  is  placed  nearly  f  of  an  inch  below 
the  corresponding  joint.  The  middle  folds  are 
double  for  all  the  fingers,  and  are  exactly  oppo- 
site the  proximal  interphalangeal  joints.  The 
distal  creases  are  single,  and  are  placed  a  little 
above  the  corresponding  joints  (1  to  2  mm.,  ac- 
cording to  Paulet).     There  are  two  single  creases 


Chap.  XV]         THE    WRIST    AND    HAND  295 

on  the  thumb  corresponding  to  the  two  joints, 
the  higher  crossing  the  metacarpophalangeal 
articulation  obliquely.  The  free  edge  of  the  web 
of  the  fingers,  as  measured  from  the  palmar  sur- 
face, is  about  |  of  an  inch  from  the  metacarpo- 
phalangeal joints.  The  superficial  palmar  arch 
may  be  represented  Ey  a  curved  line  across  the 
patm  starting  from  the  piriform  bone  and  rum 
nmg  in  a  line  with  the  palmar  border  of  the 
thumb  when  outsti-etched_al,  right  angles  with  the 
"index  flngei\  The  deep  arch  is  beween  ^  and  £ 
an  inch  nearer  the  wrist,  and  its  position  may 
be  accurately  marked  by  a  line  drawn  from  the 
base  of  the  fifth  metacarpal  to  the  base  of  the 
second,  two  easily  distinguished  points.  The 
digital  arteries  bifurcate  about  ^  an  inch  above 
the  clefts  between  the  fingers  (Fig.   50). 

The  dorsal  surface  of  the  hand. — On  the  outer 
side  of  the  wrist,  when  the  thumb  is  extended,  a 
hollow  is  obvious  between  the  extensores  ossis 
metacarpi  and  brevis  pollicis  and  the  extensor 
longus  pollicis.  French  writers  have  termed  this 
hollow  "  tabatiere  ana^n^^."  Across  this 
hollow  and  beneath  the  tendons  just  named  runs 
the  radial  artery.  Under  the  skin  over  the  space 
can  usually  be  seen  a  large  vein,  the  cephalic 
vein  of  the  thumb.  Across  the  space  also  runs 
the  external  division  of  the  terminal  branch  of 
the  radial  nerve.  In  the  floor  of  the  "  snuff-box  " 
are  the  scaphoid  bone  and  the  trapezium.  The 
extensor  longus  pollicis  crosses  the  apex  of  the 
first  interosseous  space.  The  sesamoid  bones  of 
the  thumb  and  the  joint  between  the  trapezium 
and  the  first  metacarpal  bone  can  all  be  well 
made  out.  The  latter  articulation  is  situate  in 
the  floor  of  the  "  tabatiere."  On  the  back  of  the 
hand  the  various  tendons  and  the  surface  veins, 
too,  can  all  be  clearly  distinguished.  Between 
the  first  and  second  metacarpal  bones  is  the  Ursj^ 
clorsal  interosseous  muscle,  which~^f5rms  a  con-' 
s'picuOus  prominence  when  the  thumb  is  pressed 
against  the  side  of  the   index   finger.     The  three 


296  SURGICAL    APPLIED    ANATOMY     [Part  III 

rows  of  knuckles  are  formed  by  the  proximal  bones 
of  the  several  joints. 

The  wrist  and  hand. — The  skin  of  the  palm 
and  of  the  front  of  the  fingers  is  thick  and  dense, 
while  that  on  the  back  of  the  hand  is  much  finer. 
The  palm,  the  fronts  and  sides  of  the  fingers, 
and  the  dorsal  aspects  of  the  last  phalanges,  all 
show  an  entire  absence  of  hair  and  of  sebaceous 
glands.  These  parts  are,  therefore,  exempt  from 
the  maladies  that  attack  hair  follicles  and  their 
gland  appendages.  On  the  dorsum  of  the  hand, 
and  of  the  first  and  second  rows  of  phalanges, 
there  are  numerous  hairs  and  sebaceous  follicles. 
Sweat  glands  are  more  numerous  in  the  skin  of 
the  palm  than  in  any  other  part.  According  to 
Sappey  they  are  four  times  more  numerous  here 
than  they  are  elsewhere.  Krause  has  estimated 
that  nearly  2_,800  of  these  glands  open  upon  a 
square  inch  of  the  palm.  Only  about  half  the 
number  are  found  upon  the  dorsum  of  the  hand. 
The  profuseness  with  which  the  palm  may  per- 
spire is  well  known,  and  is  very  marked  in  certain 
conditions.  The  cutaneous  nerve-supply  of  the 
hand  is  very  free.  The  nerves  present  Pacinian 
bodies,  which  are  far  more  numerous  in  the  hand 
than  in  any  other  part.  With  the  exception  of  the 
tip  of  the  tongue,  a  more  acute  degree  of  tactile 
sensibility  is  met  with  in  the  hand  than  elsewhere 
in  the  body.  The  most  sensitive  district  is  the 
palmar  surface  of  the  third  phalanx  of  the  index 
finger,  while  the  least  sensitive  to  tactile  im- 
pressions is  the  dorsum  of  the  hand.  It  may  be 
said  that  the  tips  of  the  fingers  are  about  thirty 
times  more  acute  to  the  sense  of  touch  than  is  the 
skin  of  the  middle  of  the  forearm,  which  is  among 
the  least  sensitive  portions  of  the  integument  as 
regards  tactile  influences. 

The  subcutaneous  tissue  of  the  front  of  the 
hand,  and  especially  of  the  palm,  is  scanty  and 
dense,  and  somewhat  resembles  the  subcutaneous 
tissue  of  the  scalp  in  that  the  skin  is  closely  ad- 
herent to  it,  and  the  fat  it  contains  is  arranged  in 


Chap.  XV]         THE    WRIST    AND    HAND  297 

minute  lobules  lodged  in  lacunae.  Cutaneous 
ligaments  bind  the  skin  down  at  the  creases  of 
the  palm  and  fingers.  The  subcutaneous  tissue 
on  the  dorsum,  however,  is  lax,  and  has  but  a 
frail  association  with  the  skin.  Thus  it  follows 
that  subcutaneous  extravasations  of  blood  are 
practically  impossible  in  the  palm  and  on  the 
anterior  aspect  of  the  fingers,  while  they  may  be 
very  extensive  on  the  dorsum.  In  like  manner 
oedema  of  the  extremity  is  conspicuously  marked 
upon  the  dorsal  surface,  while  the  palm  remains 
comparatively  free  even  in  severe  cases.  The 
denseness  of  the  integuments  of  the  palm  renders 
inflammation  of  the  part  extremely  painful, 
owing  to  the  tension  that  is  so  readily  produced, 
whereas  inflammation  in  the  lax  tissues  of  the 
dorsum  may  reach  some  magnitude  without  caus- 
ing great  pain.  The  palm  of  the  hand  is  well 
adapted  to  meet  the  effects  of  pressure  and  fric- 
tion. The  cuticle  is  thick,  the  skin  is  adherent, 
and  immediately  beneath  it  lies  the  dense  palmar 
fascia.  This  fascia  efficiently  protects  the  palmar 
nerves  and  the  main  vessels,  while  it  must  be 
noted  that  the  front  of  the  hand,  and  especially 
the  palm,  is  singularly  free  from  surface  veins. 
Indeed,  the  great  bulk  of  the  blood  from  the  hand 
is  returned  by  the  superficial  veins  on  the  dorsum 
of  the  fingers  and  hand.  In  like  manner,  the 
lymphatics  of  the  palm,  which  form  a  rich  sub- 
cutaneous plexus,  join  the  large  efferent  lym- 
phatics on  the  dorsum  of  the  hand. 

The  form  of  the  nail  varies  somewhat  in  in- 
dividuals, and,  according  to  certain  authors, 
there  are  special  types  of  nail  to  be  met  with  in 
some  constitutional  diseases.  By  the  Hippocratic 
hand  is  meant  a  hand  the  tips  of  the  fingers  of 
which  are  clubbed  and  the  nails  of  which  are 
much  curved.  This  condition  would  appear  to  be 
due  to  impeded  circulation  by  retardation  in  the 
return  of  venous  blood,  and  perhaps  also  to  im- 
perfect oxygenation  of  that  blood.  It  is  most 
often    met   with    in    congenital    heart    disease,    in 


298  SURGICAL   APPLIED    ANATOMY    [Part  III 

phthisis,  empyema,  chronic  lung  affections,  and 
certain  thoracic  aneurisms.  There  are  several 
forms  of  inflammation  affecting  the  matrix  of  the 
nail  and  the  soft  parts  immediately  around  it 
(onychia,  paronychia).  Such  inflammations  lead 
to  great  deformity  of  the  structure  itself.  When 
a  nail  is  thrown  off  by  suppuration  or  violence 
a  new  nail  is  produced,  provided  any  of  the 
deeper  epithelial  cells  are  left.  During  conval- 
escence from  certain  illnesses  {e.g.  scarlet  fever), 
a  transverse  groove  will  appear  across  all  the 
nails.  This  groove  indicates  the  portion  of  nail 
formed  during  the  illness,  and  by  watching  its 
movement  the  rate  of  growth  of  the  nail  can  be 
estimated.  The  nail  grows  at  the  average  rate  of 
a^nd  of  an  inch  per  week;  if  the  hand  is  im- 
mobilised by  splints  the  rate  of  growth  is  retarded 
(Head).  It  may  be  noted  that  each  digital  nerve 
gives  a  special  branch  of  large  size  to  the  pulp 
beneath  the  nail,  and  this  explains  the  intense 
pain  felt  when  a  foreign  body  is  thrust  under 
the  nail. 

The  fascise.  — Beneath  the  skin  of  the  palm  is 
the  dense  palmar  fascia.  This  fascia  gives  almost 
as  much  strength  to  the  hand  as  would  so  much 
bone,  while  its  unyielding  character,  its  com- 
parative freedom  from  vessels  and  nerves,  render 
it  well  suited  to  withstand  the  effects  of  pressure. 
The  fascia  gives  slips  to  each  finger ;  each  slip 
sends  fibres  to  join  the  digital  sheaths  of  the 
tendons,  the  skin,  and  the  superficial  transverse 
ligament.  In  the  disease  known  as  Dupuytren's 
contraction,  the  palmar  fascia,  and  especially  its 
digital  slips,  becomes  contracted.  One  or  more 
or  all  of  the  fingers  may  be  involved  in  the  con- 
traction. The  proximal  phalanx  is  drawn  or 
flexed  towards  the  palm,  and  later  the  second 
phalanx  becomes  bent  also.  The  skin  is  drawn 
in  towards  the  fascia,  since  the  two  structures 
are  normally  connected  with  one  another.  Ex- 
periment shows  that  by  dragging  upon  the  fascia 
the   proximal   phalanx  can   be   readily  bent,   and 


Chap.  XV]         THE    WRIST    AND    HAND 


299 


also,  but  with  less  ease,  the  middle  phalanx.  The 
middle  part  of  the  palmar  fascia  represents  the 
tendon  of  the  palmaris  longus  in  the  hand. 

The   structures  of  the   palm  are   divided   into  ' 
three   spaces   by   the   fascia    (Fig.    51).     Thus   the 
muscles  of  the  thenar  and  hypothenar  eminences 
are  both  enclosed  in  a  thin  fascia  proper  to  each. 
The   two   spaces   formed   by   these   membranes   are 


h     (J\  \ 


Wo  ,  if  - 


Fig.   51.—  Horizontal   section    of  the  hand    through   the   middle   of   the 
thenar  and  hypothenar  eminences.     (Tillaux.) 

a,  Metacarpal  bone;  &,  Hist  dorsal  interosseous;  c,  palmaris  brevis;  d,  abductor 
niin.  diyriti :  e, flexor  brevis  niiii.  dig.;/  opponens  min.  dig.;  g, flexor  brevis 
poll.;  //,  abductor  poll.;  i,  Opponens  poll.;  j,  adductor  poll.;  fc,  flexor  long 
poll.:  .',  dorsal  interossei:  m,  palmar  interossei;  ;/,  flexor  sublimis;  o,  flexor 

profundus  j  />,  supeiUc.  volae :  q,  median  nerve,  and  (on  inner  side)  ulnar  artery 
and  nerve  ;  r,  deep  palmar  areli  ;  1,  palmar  fascia  ;  l',  outer  septum  ;  :%  inner 
septum:  -4,  deep  fascia  of  palm. 

enclosed  in  all  directions,  and  are  capable,  though  \ 
only    in    a    feeble    way,    of    limiting    suppuration  1 
when  it  commences  in  them.     Between  these  two/ 
spaces   is   a   third   space,    which   is   roofed   in   by/ 
the  palmar  fascia.     This  cavity  is  closed  in  at  the) 
sides,  but  is  open  above  and  below.     Above  there/ 
is  a  free  opening  beneath  the  annular   ligament 
and   along   the   flexor   tendons   into  the   forearm, 
while  below  there  are  the  seven  passages  provided 
for  by  the  division  of  the  palmar  fascia.     Of  these 
seven   passages,   four,   situate  at  the  roots  of  the 


300         i    SURGICAL    APPLIED    ANATOMY    [Part  III 

several  fingers,  give  passage  to  the  flexor  tendons, 
while  the  remaining  three  correspond  to  the  webs 
between  the  lingers,  and  give  passage  to  the  lum- 
bricales  and  the  digital  vessels  and  nerves.  When 
pus,  therefore,  forms  on  the  palm,  beneath  the 
palmar  fascia,  it  cannot  come  forward  through 
that  dense  membrane,  but  escapes  rather  along  the 
fingers  or  makes  its  way  up  into  the  forearm. 
So  rigid  is  the  resistance  offered  by  the  palmar 
fascia,  that  pent-up  pus  will  make  its  way  through 
the  interosseous  spaces  and  appear  on  the  dorsum 
of  the  hand,  rather  than  come  through  the  cover- 
ings of  the  palm.  The  passage  of  pus,  however, 
towards  the  dorsum  is  resisted  by  a  layer  of  fascia 
that  lies  deeply  beneath  the  flexor  tendons,  and 
covers  in  the  interossei  muscles,  the  bones,  and 
the  deep  palmar  arch.  This  fascia  joins  on  either 
side  the  fasciae  enclosing  the  thenar  and  hypo- 
thenar  "  spaces  "   (Fig.  51). 

In  opening  a  palmar  abscess,  when  it  points 
above  the  wrist,  the  incision  should  be  in  the  long 
axis  of  the  forearm,  should  be  above  the  annular 
ligament,  and  is  most  conveniently  made  a  little 
to  the  ulnar  side  of  the  palmaris  longus,  for  a 
cut  in  this  position  would  escape  both  the  ulnar 
and  radial  arteries  and  also  the  median  nerve. 

The  tendons  about  the  wrist  are  bound  down 
and  held  in  place  by  the  annular  ligaments.  So 
dense  is  the  anterior  ligament,  that  even  in  ex- 
tensive abscess  of  the  palm  reaching  into  the  fore- 
arm, and  in  severe  distension  of  the  synovial 
sheaths  beneath  the  ligament,  it  remains  firm,  and 
will  not  yield.  The  lower  border  of  the  poster  in  r 
annular  ligament  corresponds  to  the  uppeT~~edge 
of  the  anterior  band,  and  these  structures  together 
act  the  parE  of  the  leather  bracelet  that  the 
labourer  sometimes  wears  around  his  wrist,  ah d 
that,  in  fact,  takes  the  function  of  an  additional 
annular  ligament 

The  fibrous  slieatlis  for  the  flexor  tendons 
extend  from  the  metacarpophalangeal  joints  to 
the  upper  ends  of  the  distal  phalanges.     The  pulp 


Chap.  XVJ         THE    WRIST    AND    HAND 


301 


h 


of  the  third  phalanx,  therefore,  rests  practically 
upon  the  periosteum.  Opposite  the  finger-joints 
the  sheaths  are  lax  and  thin,  and  spaces  may 
occur  between  the  decussating  fibres  of  the  sheaths, 
through  which  the  synovial  membrane  lining  the 
sheath  may  protrude.  It  is,  I  believe,  through 
this  less  protected  part  of  the  sheath 
that  suppuration  without  often  finds 
its  way  into  the  interior  of  the 
sheath.  The  sheaths  in  the  rest  of 
their  course  are  dense  and  rigid,  and 
when  cut  across  remain,  in  virtue  of 
this  rigidity,  wide  open  (Fig.  52). 
Thus,  after  the  division  of  the  sheath, 
as  in  amputation,  an  open  channel  is 
left  leading  into  the  palm  of  the 
hand,  and  offering  the  greatest 
facility  for  the  spread  of  pus  into 
that  part.  It  is  this  rigidly  open 
fibrous  sheath  that  probably  may  ex- 
plain the  frequency  of  suppuration 
in  the  palm  after  amputation  of  a 
part  of  a  finger,  and  I  am  decidedly 
of  opinion  that  some  steps  should  be  taken  to 
protect  or  shut  off  this  channel  in  any  case  where 
the  sheath  has  been  accidentally  or  intentionally 
divided. 

The  tendons  accurately  fill  the  fibrous  sheaths. 
A  gangliform  growth  on  the  tendon  as  it  enters 
the  sheath,  or  a  constriction  of  the  sheath  with  an 
inequality  in  the  tendon,  gives  rise  to  the  con- 
dition known  as  "  snap  ;'  finger.  Such  a  digit 
cannot  be  extended  by  will,  but  when  pushed  a 
little  way  "  springs  back  with  a  snap  like  the 
blade  of  a  pocket  knife  ,:  (Abbe).  "  Congenital 
"  of  the  little  finger  is  very  common 
degree.  In  marked  cases,  the  prox- 
imal phalanx  is  hyper-extended  and  the  middle 
flexed.  Lock  wood  found  in  such  a  case  that  the 
condition  was  due  to  a  contraction  in  the  fibrous 
sheath  in  front  of  the  joint.  Contracted  finger 
following  whitlow  is   due   to   an   adhesion   of  the 


Fig.  52.  —  Hori- 
zontal section 
through  middle 
of  second  phal- 
anx.   (TiUaitx.) 

a,  Flexor  tendon  j 
b,  fibrous  sheath 
of  tendon  ;  r,  ex- 
tensor tendon  ; 
d,  digital  artery 
and  nerve., 


contraction 
slight 


in   a 


302  SURGICAL    APPLIED    ANATOMY     [Part  III 

tendons  to  their  sheath.  Paralytic  contraction  of 
the  flexor  muscles  also  brings  about  permanent 
contracture  of  the  fingers. 

Synovial  sacs  and  sheaths.— There  are  two 
synovial  sacs  beneath  the  annular  ligament  for  the 
flexor  tendons,  one  for  the  flexor  longus  pollicis, 
the  other  for  the  flexor  sublimis  and  profundus 
tendons  (Fig.  53).  The  former  extends  up  into 
the  forearm  for  about  l\  inch  above  the  annular 
ligament,  and  follows  its  tendon  to  its  insertion 
in  the  last  phalanx  of  the  thumb.  The  latter 
rises  about  \\  inch  above  the  annular  band, 
and  ends  in  diverticula  for  the  four  fingers.  The 
process  for  the  little  finger  usually  extends  to  the 
insertion  of  the.  flexor  profundus  tendon  in  the 
last  phalanx.  The  remaining  three  diverticula 
end  about  the  middle  of  the  corresponding  meta- 
carpal bones.  The  synovial  sheaths  for  the  digital 
part  of  the  tendons  to  the  index,  middle,  and  ring 
fingers  end  above  about  the  neck  of  the  meta- 
carpal bones,  and  are  thus  separated  by  about  \ 
to  \  an  inch  from  the  great  synovial  sac  beneath 
the  annular  ligament.  Thus  there  is  an  open 
channel  from  the  ends  of  the  thumb  and  little 
finger  to  a  point  in  the  forearm  some  lh  inch 
above  the  annular  ligament.  The  arrangement 
explains  the  well-known  surgical  fact  that  ab- 
scesses of  the  thumb  anu  little  finger  are  apt  to  be 
followed  by  _  abscesses  in  the  forearm,  while  such 
a  complication  is  not  usual  after  suppuration  in 
the  remaining  fingers.  The  synovial  sac  for  the 
flexor  tendons  is  narrowed  as  it  passes  beneath 
the  annular  ligament,  and  thus  it  happens  that 
when  distended  with  fluid  or  with  pus,  it  presents 
an  hour-glass  outline,  the  waist  of  the  hour-glass 
corresponding  to  the  ligament.  The  two  synovial 
sacs  beneath  the  ligament  sometimes  communicate 
with  one  another.  The  tendon  of  the  flexor  carpi 
radialis  perforates  the  insertion  of  the  annular 
ligament  to  the  trapezium;  it  is  surrounded  by  a 
synovial  sheath  (Fig.  53). 

In  one  form  of  whitlow,  that  form  where  the 


Chap.  XV]        THE    WRIST    AND    HAND 


303 


pus  occupies  the  synovial  sheaths  of  the  tendons 
on  the  fingers  (thecal  abscess),  the  suppuration 
can  often  be  seen  to  end  abruptly  where  the  sheath 
ends,  when  the  index,  middle,  or  ring  finger  is 
involved,  viz.  opposite  the  neck  of  the  corre- 
sponding metacarpal  bones.     In  another  form  of 


Flexor   Digitorum 

Unciform 
Pisiform 
Wrist  Folds 
Styloid  Process 


Flex.  Longus  Pollicis 

Trapezium 
Ant.  Annular  Ligament 
Scaphoid 

Flexor  Carp.  Radialis 
Styolid  Process 


Fig.   53.— The    anterior    annular    ligament    of   the   wrist    and   synovial 
sheaths  of  the  wrist  and  hand. 

The  creases  of  the  hand  are  indicated  by  black  lines ;  the  synovial  sheaths  are 

shown  in  red. 


whitlow  (the  abscess  in  the  pulp  at  the  end  of  the 
finger)  the  periosteum  of  the  third  phalanx  is 
readily  attacked,  there  being  no  intervening  ten- 
don sheath  over  that  bone.  In  this  affection  the 
bone  often  necroses  and  comes  away,  but  it  is  sig- 
nificant to  note  that  it  is  very  seldom  that  the 
whole  of  the  phalanx  perishes.  The  upper  part, 
or  base,  of  the  bone  usually  remains  sound,  and  is 
probably  preserved  by  the  insertion  of  the  flexor 


304  SUEGICAL    APPLIED    ANATOMY     [Part  III 

profundus  tendon.  It  is  also  interesting  to  bear 
in  mind  that  the  base  of  the  bone  is  an  epi- 
physis that  does  not  unite  to  the  shaft  until  the 
eighteenth  or  twentieth  year. 

The  tendons  do  not  lie  free  within  the  sac,  but 
are  bound  to  it  by  folds  of  synovial  membrane  in 
much  the  same  way  as  the  bowel  is  bound  to  the 
abdominal  parietes  by  its  mesentery.  These  folds 
may  be  ruptured  in  severe  sprains,  when  the 
nutrient  vessels  for  the  tendon,  which  are  con- 
tained in  them,  may  be  torn:  Rupture  is  followed 
by  effusion  into  the  sac.  These  folds  are  almost 
absent  within  the  digital  sheaths,  the  slight  liga- 
menta  longa  and  brevia,  near  the  insertion  of 
the  tendons,  being  their  sole  representatives.  Syn- 
ovial sacs  are  lined  by  a  squamous  epithelium,  and 
have  extremely  free  communication  with  the  lym- 
phatic vessels  of  the  part.  Hence  the  free  absorp- 
tion of  infective  matter  from  such  cavities. 

Beneath  the  posterior  annular  ligament  there 
are  six  synovial  sheaths  for  tendons,  correspond- 
ing to  the  six  canals  formed  by  that  ligament. 
The  sheath  most  frequently  inflamed  is  that  for 
the  extensores  ossi  metacarpi  and  brevis  pollicis. 
It  runs  from  a  point  about  f  of  an  inch  above  the 
radial  styloid  process  to  the  first  carpo-meta- 
carpal  joint.  The  other  sheaths  reach  above  to 
the  upper  border  of  the  annular  ligament,  that 
for  the  two  radial  extensors,  however,  beginning 
about  |  an  inch  above  the  ligament.  The  sheaths 
for  the  extensor  communis  and  the  extensor 
minimi  digiti  extend  below  to  the  middle  of  the 
metacarpus.  That  for  the  extensor  indicis  barely 
reaches  the  metacarpus.  The  other  sheaths  follow 
the  tendons  to  their  insertions.  The  synovial  lin- 
ing and  folds  of  these  sheaths  are  injured  in 
Colles'  fracture  of  the  radius.  The  tendons  be- 
come adherent  and  fixed  to  their  sheaths  unless 
this  be  prevented  by  passive  movements  of  the 
tendons. 

Blood-vessels  and  lymphatics.— The  hand 
is  very  well  supplied  with  blood,  and  indeed  the 


Chap.  XV]         THE    WRIST    AND    HAND  305 

finger  pulp  is  one  of  the  most  vascular  parts  in 
the  body.  Cases  arc  recorded  where  the  tip  of  the 
finger  has  been  accidentally  cut  off,  and  has  grown 
again  to  the  limb  on  being  immediately  re- 
applied. The  position  of  the  palmar  arches  has 
been  pointed  out.  Wounds  of  these  arches,  and 
indeed  of  most  of  the  arteries  of  the  palm  and 
wrist,  are  serious,  on  account  of  the  difficulty  of 
reaching  the  bleeding  point  without  severely 
damaging  important  structures,  and  on  account 
of  the  free  anastomoses  that  exist  between  the 
vessels  of  the  part.  The  deep  palmar  arch  may  be 
wounded  by  a  penetrating  wound  from  the  dor- 
sum, and  indeed  Delorme  has  pointed  out  that 
this  arch  may  be  ligatured  from  the  dorsum  after 
a  preliminary  resection  of  the  upper  part  of  the 
third  metacarpal  bone.  It  is  well  known  that 
haemorrhage  from  either  of  the  palmar  arches  can- 
not be  checked  by  ligature  of  the  radial  or  ulnar 
artery  alone,  on  account  of  the  connection  of  the 
arches  with  those  vessels;  and  it  is  also^  known 
that  simultaneous  ligation  of  tne  tw"o~vessels  may 
have  no  better  effect,  owing  to  the  anastomoses 
between  the  palmar  arches  and  the  interosseous 
vessels.  The  anastomosis  between  the  two  palmar 
arches  is  well  known,  and  is  freely  established 
both  by  the  main  vessels  themselves  and  by  the 
communion  that  exists  between  the  digital  arteries 
from  the  superficial  arch  and  the  palmar  inter- 
osseous branches  from  the  deeper  vessels.  In 
bleeding  from  the  palm,  the  simultaneous  ligature 
of  the  radial  and  ulnar  arteries  may  also  entirely 
fail  in  those  cases  where  the  arches  are  freely 
joined,  or  are  more  or  less  replaced  by  large  and 
abnormal  interosseous  vessels,  or  by  a  large 
"  median  "  artery.  When  either  the  radial  or  the 
ulnar  part  of  the  arches  is  defective,  the  lack  is 
usually  supplied  by  the  other  vessel ;  and  it  is 
well  to  note  that  the  deficiency  is  most  common 
in  the  superficial  or  ulnar  arch.  Pressure  ap- 
plied to  the  palm  to  arrest  bleeding  is  apt  to  cause 
gangrene,  owing  to  the  rigidity  of  the  parts  and 
u 


306  SUKGICAL    APPLIED    ANATOMY      [Part  III 

the  ease  with  which  considerable  pressure  can  be 
applied. 

The  radial  artery,  as  it  curves  round  the  back 
of  the  hand  to  reach  the  deeper  part  of  the  palm, 
is  in  close  contact  with  the  carpo-metacarpal 
joint  of  the  thumb.  This  fact  must  be  borne  in 
mind  in  amputation  of  the  entire  thumb,  and  also 
in  resection  of  the  first  metacarpal  bone.  The 
superficialis  volae,  if  large,  may  bleed  seriously. 
It  adheres  to  the  surface  of  the  annular  ligament, 
and  may  therefore  be  difficult  to  pick  up  when 
wounded. 

From  the  larger  size  and  great  number  of  the 
lymphatics  about  the  fingers  and  on  the  dorsum  of 
the  hand,  it  follows  that  lymphangitis  is  more 
common  after  wounds  of  those  parts  than  it  is 
after  wounds  of  the  palm. 

The  l>ones  and  joints. — The  inferior  radio- 
ulnar joint  is  supported  by  the  powerful  tri- 
angular fibro-cartilage,  which  forms  the  strong- 
est and  most  important  of  all  the  ligamentous 
connections  between  the  two  bones.  The  synovial 
sheath  of  the  extensor  minimi  digiti  sometimes 
communicates  with  this  joint,  and  may  therefore 
be  involved  when  that  articulation  is  diseased. 

The  strength  of  the  wrist-joint  depends  not  so 
much  upon  its  mechanical  outline  or  its  liga- 
ments as  upon  the  numerous  strong  tendons  that 
surround  it,  and  that  are  so  closely  bound  down 
to  the  bones  about  the  articulation.  Moreover,  in 
the  case  of  the  wrist  the  long  lever  does  not  exist 
on  the  distal  side  of  the  joint.  The  anterior  liga- 
ment of  the  wrist  is  the  strongest  ligament  of  the 
joint,  while  the  posterior  is  the  weakest.  The 
former  structure  limits  extension,  and  the  latter 
flexion ;  and  in  connection  with  this  arrangement 
it  is  interesting  to  note  that  injury  from  forced 
extension  is  more  common  than  from  forced 
flexion.  Thus,  when  a  man  falls  upon  the  hand, 
he  more  usually  falls  upon  the  palm  (forced  ex- 
tension) than  upon  the  dorsum  (forced  flexion). 
Owing  to  the  thinness  of  the  posterior  ligament, 


Chap.  XV]        THE    WRIST    AND    HAND  307 

together  with  the  more  superficial  position  of  the 
hinder  part  of  the  joint,  it  follows  that  the  effu- 
sion in  wrist-joint  disease  is  first  noticed  at  the 
back  of  the  hand. 

Movemeuts  at  the  wrist  take  place  as  freely 
in  the  intercarpal  joint  (between  the  first  and 
second  row  of  carpal  bones)  as  in  the  radio-carpal 
joint.  The  axis  of  the  radio-carpal  joint  is  such 
that  in  flexion  the  palm  turns  towards  the  ulnar 
side  of  the  forearm ;  while  in  flexion  at  the  mid- 
carpal  joint  the  palm  moves  towards  the  radial 
side.  When  movement  takes  place  at  both  joints 
these  tendencies  are  balanced  and  pure  flexion  is 
produced.  The  tendon  of  the  extensor  carpi  ul- 
naris  is  placed  anteriorly  to  the  axis  of  the  mid- 
carpal  joint,  but  behind  the  radio-carpal,  and 
therefore  produces  flexion  in  one  joint  and  exten- 
sion in  the  other  (Ashdowne).  The  muscles  which 
act  on  the  wrist  exemplify  the  various  parts  which 
muscles  play  in  producing  a  purposeful  move- 
ment. A  muscle  may  act  as  (1)  a  prime  mover,  (2) 
an  antagonist,  (3)  a  synergic  muscle,  (4)  a  fixation 
muscle.  For  instance,  when  the  fingers  are  flexed  : 
the  deep  and  superficial  flexors  are  the  prime 
movers;  the  antagonists  in  action  are  the  exten- 
sors of  the  fingers ;  the  flexors  of  the  fingers  would 
also  produce  flexion  at  the  wrist  were  not  the  ex- 
tensors of  the  wrist  also  thrown  into  action  as 
synergic  muscles ;  when  the  extensors  of  the  fingers 
act,  the  flexors  of  the  wrist  contract;  in  flexing 
and  extending  the  fingers  the  wrist  can  be  ren- 
dered immovable  by  the  flexors  and  extensors  of 
the  carpus,  which  then  act  as  muscles  of  fixation. 
Thus  a  movement  which  appears  simple  results 
from  the  action  of  groups  of  muscles,  and  it  is 
this  complexity  which  makes  the  diagnosis  of 
nerve  lesions  from  a  study  of  the  action  of  mus- 
cles so  difficult.  What  has  been  said  of  the  muscles 
of  the  wrist  applies  equally  to  all  the  muscles 
of  the  body.  (See  Beevor's  Croonian  Lectures, 
1903.) 

But  little  movement  is  allowed  in  the  carpo- 


308  SURGICAL    APPLIED    ANATOMY      [Part  III 

metacarpal  joints  of  the  first  three  fingers,  but 
in  the  like  joints  of  the  thumb  and  little  finger 
movements  are  free,  and  their  preservation  is  of 
great  importance  to  the  general  usefulness  of  the 
hand.  The  glenoid  ligaments  in  front  of  the  three 
finger-joints  are  firmly  attached  to  the  distal  bone, 
and  but  loosely  to  the  proximal.  Thus  it  happens 
that  in  dislocation  of  the  distal  bone  backwards, 
the  glenoid  ligament  is  carried  with  it,  and  offers 
a  great  obstacle  to  reduction.  In  flexing  the 
middle  and  distal  phalanges  alone,  it  will  be  seen 
that  the  proximal  phalanx  is  steadied  by  the 
extensor  tendon  as  a  preliminary  measure,  and  in 
paralysis  of  the  extensors,  flexion  of  these  two 
joints  alone  is  not  possible. 

Very  few  persons  have  the  power  of  flexing  the 
last  finger-joint  without  at  the  same  time  bending 
the  articulation  above  it;  but  in  certain  inflam- 
matory affections  about  the  last  phalanges  the 
terminal  joint  is  sometimes  seen  to  be  fixed  in  a 
flexed  posture  while  the  other  finger-j'oints  are 
straight.  In  the  condition  known  as  "  mallet  " 
finger  the  distal  phalanx  is  fixed  in  a  flexed  posi- 
tion. The  condition  is  due  to  a  partial  or  com- 
plete rupture  of  the  extensor  tendon  of  the  finger, 
commonly  the  result'  of  a  blow  over  the  terminal 
knuckles. 

Colles'  fracture.  —  This  name  is  given  to  a 
transverse  fracture  through  the  lower  end  of  the 
radius,  from  \  to  1  inch  above  the  wrist-joint. 
It  is  associated  with  a  certain  definite  deformity, 
and  is  always  the  result  of  indirect  violence,  a 
fall  upon  the  outstretched  hand.  There  are  good 
reasons  why  the  bone  should  break  in  this  situa- 
tion. The  lower  end  of  the  radius  is  very  can- 
cellous, while  the  shaft  contains  a  good  deal  of 
compact  bone.  At  about  f  of  an  inch  from  the 
articular  surface  these  two  parts  of  the  bone  meet, 
and  their  very  unequal  density  greatly  tends  to 
localise  the  fracture  in  this  situation.  As  to  the 
mechanism  of  this  lesion,  many  different  opinions 
are  still  held,  and  a  vast  deal  has  been  written 


Chap.  XV]        THE    WRIST   AND   HaND  309 

on  the  subject.  I  subjoin  Professor  Ohiene's  ac 
count  of  this  lesion,  because  it  may  be  taken  as 
representing  with  admirable  clearness  the  views 
most  generally  accepted  at  the  present  time  as  to 
the  nature  of  this  injury.  Into  the  discussion 
itself  I  do  not  propose  to  enter.  The  deformity 
in  Colles'  fracture  is  entirely  due  to  the  displace- 
ment of  the  lower  fragment.  "  The  displacement 
is  a  triple  one  :  (a)  backwards,  as  regards  the 
antero-posterior  diameter  of  the  forearm;  (6) 
rotation  backwards  of  the  carpal  surface  on  the 
transverse  diameter  of  the  forearm ;  (c)  rotation 
through  the  arc  of  a  circle,  the  centre  of  which 
is  situated  at  the  ulnar  attachment  of  the  tri- 
angular ligament,  the  radius  of  the  circle  being 
a  line  from  the  ulnar  attachment  of  the  triangular 
ligament  to  the  tip  of  the  styloid  process  of  the 
radius,  (a)  When  a  person  in  falling  puts  out 
his  hand  to  save  himself,  at  the  moment  the  hand 
reaches  the  ground  the  force  is  received  princi- 
pally by  the  ball  of  the  thumb,  and  passes  into 
the  carpus,  and  thence  into  the  lower  end  of  the 
radius.  If,  at  the  moment  of  impact,  the  angle 
between  the  axis  of  the  forearm  and  the  ground 
is  less  than  60°,  the  line  representing  the  direction 
of  the  force  passes  upwards  in  front  of  the  axis  of 
the  forearm ;  the  whole  shock  is  therefore  borne 
by  the  lower  end  of  the  radius,  which  is  broken 
off,  and,  the  force  being  continued,  the  lower  frag- 
ment is  driven  backwards.  When  at  the  moment 
of  impact  the  angle  is  greater  than  60°,  the  line 
of  the  force,  instead  of  passing  in  front  of  the 
axis  of  the  arm,  passes  up  the  arm,  and  the  usual 
result  is  either  a  severe  sprain  of  the  wrist  or  a 
dislocation  of  the  bones  of  the  forearm  backwards 
at  the  elbow-joint,  (b)  The  carpal  surface  of  the 
radius  slopes  forwards,  and  therefore  the  pos- 
terior edge  of  the  bone  receives  the  greater  part 
of  the  shock ;  there  is,  as  a  result,  rotation  of  the 
lower  fragment  backwards  on  the  transverse  dia 
meter  of  the  forearm,  (c)  The  carpal  surface 
of    the    radius    slopes    downwards   and    outwards 


310  SUEGICAr  APPLIED    ANATOMY     [Part  III 

to  the  radial  edge  of  the  arm ;  therefore  the  radial 
edge  of  the  bone  receives  the  principal  part  of 
the  shock  through  the  ball  of  the  thumb.  As  a 
result,  this  edge  of  the  lower  fragment  is  dis- 
placed upwards  to  a  greater  extent  than  the 
ulnar  edge  of  the  fragment,  which  remains  firmly 
attached  to  the  ulna  by  the  triangular  liga- 
ment." 

In  over  50  per  cent,  of  cases,  the  styloid  process 
of  the  ulna  is  also  broken  by  the  force  transmitted 
to  it  through  the  triangular  fibro-cartilage  (Mor- 
ton). By  means  of  this  rotatory  displacement,  the 
tips  of  the  two  styloid  processes  come  to  occupy  the 
same  level,  or  the  radial  process  may  even  mount 
above  the  ulnar.  In  nearly  every  case  there  is 
some  penetration  of  the  fragments,  the  compact 
tissue  on  the  dorsal  aspect  of  the  upper  fragment 
being  driven  (by  a  continuation  of  the  force  that 
broke  the  bone)  into  the  cancellous  tissue  on  the 
palmar  aspect  of  the  lower  fragment.  It  is  only 
in  very  rare  instances  that  the  fragments  are  so 
separated  as  to  ride  the  one  over  the  other.  In 
such  cases  the  radio-ulnar  ligaments  are  probably 
ruptured,  and  the  wrist  ceases  to  present  the  typi- 
cal deformity  of  a  Colles'  fracture.  In  studying 
the  radiographs  of  170  cases  diagnosed  as  Colles' 
fracture,  Dr.  R.  Morton  found  there  was  disloca- 
tion as  well  as  fracture  in  3  and  separation  of 
the  lower  radial  epiphysis  in  11  cases.  This 
epiphysis  is  often  separated  by  accidental  vio- 
lence. It  joins  the  shaft  about  the  twentieth  year. 
Its  junction  with  the  shaft  is  represented  by  a 
nearly  horizontal  line,  and  the  epiphysis  includes 
the  facet  for  the  ulna  and  the  insertion  of  the 
supinator  longus. 

Since  the  introduction  of  radiographic  methods 
of  examination,  it  has  been  found  that  many  in- 
juries, formerly  regarded  as  mere  sprains,  were 
really  due  to  fracture  or  displacement  of  carpal 
bones  or  fracture  of  a  metacarpal.  The  semilunar 
is  most  frequently  displaced  and  the  fifth  meta- 
carpal most  frequently  fractured. 


Chap.  XV]        THE    WRIST    AND    HAND  311 

Dislocations.  —  (1)  At  the  wrist-joint.  So 
strong  is  this  articulation,  for  the  reasons  above 
given  (p.  306),  that  carpo-radial  luxations  are 
extremely  rare.  For  the  same  reasons,  when  they 
do  occur  they  are  usually  complicated,  and  are 
associated  with  tearing  of  the  skin,  or  rupture 
of  tendons  or  fractures  of  the  adjacent  bones. 
The  luxations  of  the  carpus  may  be  either  back- 
wards or  forwards,  the  latter  being  extremely 
rare.  They  would  appear  to  be  produced  with 
equal  ease  by  a  fall  upon  either  the  front  or  the 
back  of  the  hand.  Bransby  Cooper  gives  the  case 
of  a  lad  who  fell  upon  the  outstretched  palms 
of  both  his  hands  :  both  wrists  were  dislocated, 
one  backwards,   the  other  forwards. 

There  are  five  articular  synovial  cavities  con- 
nected with  the  carpus.  They  occur  in  the  follow- 
ing situations  :  (a)  Between  the  carpus  and  fore- 
arm bones;  it  may  communicate  with  the  lower 
radio-ulnar  cavity  through  the  triangular  fibro- 
cartilage ;  (b)  between  the  unciform  and  the 
fourth  and  fifth  metacarpals;  (c)  between  the 
metacarpal  of  the  thumb  and  trapezium;  (d) 
between  all  the  carpal  bones  and  extending  to  the 
carpo-metacarpal  joints  of  the  second  and  third 
digits;  (e)  between  the  pisiform  and  cuneiform 
bones.  Hernial  protrusions  and  gangliform 
growths  from  these  synovial  membranes  are  fre- 
quently seen  on  the  dorsum  of  the  carpus. 

(2)  Some  dislocations  about  the  hand  (os  mag- 
num). In  forcible  flexion  of  the  hand,  the  os 
magnum  naturally  glides  backwards  and  projects 
upon  the  dorsum.  In  very  extreme  flexion  (as  in 
falls  upon  the  knuckles  and  dorsum  of  the  meta- 
carpus), this  movement  of  the  bone  backwards  may 
be  such  as  to  lead  to  its  partial  dislocation,  the 
luxation  being  associated  with  some  rupture  of 
ligaments.  In  one  recorded  case  this  luxation 
was  produced  by  muscular  force.  The  patient,  a 
lady,  while  in  labour,  "  seized  violently  the  edge 
of  her  mattress,  and  squeezed  it  forcibly."  Some- 
thing was  felt  to  give  way  in  the  hand,  and  the 


312  SURGICAL    APPLIED    ANATOMY      [Part  III 

head  of  the  os  magnum  was  found  to  be  dislocated 
backwards. 

Dislocations  at  the  metacarpophalangeal  joint 
of  the  thumb.  In  this  luxation  the  phalanx  is 
usually  displaced  backwards,  and  the  lesion  is  of 
interest  on  account  of  the  great  difficulty  often 
experienced  in  reducing  the  bone.  Many  ana- 
tomical reasons  have  been  given  to  explain  this 
difficulty,  which  are  well  summarised  by  Hamil- 
ton in  the  following  passage  :  "  Hey  believes  the 
resistance  to  be  in  the  lateral  ligaments,  between 
which  the  lower  end  of  the  metacarpal  bone 
escapes  and  becomes  imprisoned.  Ballingall, 
Malgaigne,  Erichsen,  and  Vidal  think  the  meta- 
carpal bone  is  locked  between  the  two  heads  of 
the  flexor  brevis,  or,  rather,  between  the  opposing 
sets  of  muscles  which  centre  in  the  sesamoid  bones, 
as  a  button  is  fastened  into  a  button-hole.  Pail- 
loux  and  others  affirm  that  the  anterior  ligament, 
being  torn  from  one  of  its  attachments,  falls  be- 
tween the  joint  surfaces,  and  interposes  an  effec- 
tual obstacle  to  reduction.  Dupuytren  ascribes 
the  difficulty  to  the  altered  relations  of  the  lateral 
ligaments,  ...  to  the  spasm  of  the  muscles,  and 
to  the  shortness  of  the  member,  in  consequence  of 
which  the  force  of  extension  has  to  be  applied  very 
near  to  the  seat  of  the  dislocation.  Lisfranc 
found  in  an  ancient  luxation  the  tendon  of  the 
long  flexor  so  displaced  inwards,  and  entangled 
behind  the  extremity  of  the  bone,  as  to  prevent 
reduction."  Mr.  Jonathan  Hutchinson,  jun.,  has 
recently  investigated  some  cases  and  found  that 
reduction  is  prevented  by  the  fibro-cartilaginous 
plate  on  the  palmar  aspect  of  the  joint.  The 
plate  is  firmly  attached  to  the  phalanx  and  is  dis- 
located with  it.  When  subcutaneously  divided 
from  the  extensor  aspect  of  the  thumb,  the  dis- 
location may  be  reduced  with  ease. 

\vnlsioii  of  one  or  more  fingers  may  be 
effected  by  severe  violence.  In  such  cases  the 
finger  torn  off  usually  takes  with  it  some  or  all 
of    its    tendons.      These    tendons    are    practically 


Chap.  XV]         THE    WRIST   AND    HAND  313 

drawn  out  of  the  forearm,  and  may  be  of  con- 
siderable length.  Billroth  figures  a  case  where 
the  middle  finger  wras  torn  out,  taking  with  it  the 
two  flexor  and  extensor  tendons  in  their  entire 
length.  When  one  tendon  only  is  torn  away  with 
the  finger,  it  is  usually  that  of  the  flexor  profundus. 

Amputation  sit  the  wrist- joint  by  the  cir- 
cular method.  (See  the  author's  "  Operative 
Surgery/'  In  the  dorsal  wound  will  be  cutthe 
following  tendons  :  the  extensores  longus,  indicis, 
communis,  minimi  digiti,  and  ulnaris,  the  radial 
nerve,  and  the  dorsal  branch  of  the  ulnar  nerve. 
The  two  radial  extensors  will  be  cut  short  in  the 
radial  angle  of  the  wound,  as  will  also  be  the  ex- 
tensores ossis  and  brevis.  The  radial  artery  will  be 
divided  close  to  the  radius.  In  the  palmar  wound 
will  be  found  the  ulnar  artery,  the  superficialis 
volse,  the  ulnar  and  median  nerves,  the  opponens, 
flexor  brevis,  and  abductor  pollicis  in  part,  ihe 
flexor  brevis,  opponens,  and  abductor  minimi 
digiti  in  part  (the  bulk  of  the  opponens  being- 
left  behind  on  the  hand),  and  the  tendons  of  the 
flexor  sublimis  and  flexor  carpi  radialis.  The  ten- 
dons of  the  flexor  profundus  and  flexor  longus 
pollicis  are  usually  cut  short  close  to  the  bones. 

Amputation  of  the  thumb  at  the  carpo- 
metacarpal joint  by  flaps.  In  the  palmar  flap 
will  be  cut  the  abductor,  the  short  and  long 
flexor,  the  opponens,  and  the  adductor  pollicis. 
The  extensores  ossis  and  brevis  will  be  cut  short 
in  the  posterior  angle  of  the  flap.  The  extensor 
longus  and  a  considerable  portion  of  the  abductor 
indicis  will  be  found  in  the  dorsal  flap.  The 
vessels  divided  will  be  the  two  dorsal  arteries 
of  the  thumb  and  the  princeps  pollicis.  There  is 
great  danger,  in  this  operation,  of  wounding 
the  radialis  indicis  and  the  radial  artery  itself 
where  it  begins  to  dip  into  the  palm. 

Nerve  supply  ot  the  upper  limb. — The 
symptoms  which  follow  a  lesion  to  the  nerves  of 
the  upper  limb  depend  on  the  point  injured. 
If  the  fifth  spinal   nerve  be  crushed  between  its 


314  SURGICAL    APPLIED    ANATOMY      [Part  III 

origin  in  the  spinal  cord  and  its  exit  from  the 
intervertebral  foramen,  either  from  fracture  or 
caries  of  the  cervical  vertebrae,  the  injury  is  fol- 
lowed by  paralysis,  partial  or  complete,  of  the 
rhomboids,  spinati,  deltoid,  biceps,  brachialis 
anticus,  and  supinator  longus,  but  strangely 
enough  the  lesion  is  not  accompanied  by  loss  of 
sensation.  Perhaps  the  fact  that  the  posterior 
root  of  the  fifth  cervical  nerve  is  very  small  may 
assist  to  explain  this  fact  (W.  Harris).  Injury 
to  the  cord  just  above  the  origin  of  the  eighth 
cervical  vertebra  will  leave  the  skin  of  the  ulnar 
half  of  the  arm  anaesthetic,  while  the  muscles  of 
the  fingers,  hand,  and  wrist,  and  some  of  those  at 
the  elbow  and  shoulder,  will  be  paralysed.  The 
fibres  for  the  innervation  of  the  various  groups 
of  arm  muscles  pass  out  in  quite  an  orderly  man- 
ner by  the  fifth  cervical  to  the  first  dorsal  nerve 
from  corresponding  segments  of  the  cord.  Those 
for  the  abductors  of  the  shoulder  pass  out  by  the 
fifth;  for  the  adductors  by  the  sixth  and  seventh; 
for  the  flexors  of  the  elbow  by  the  fifth  and  sixth; 
for  the  extensors  by  the  seventh  and  eighth ; 
for  the  extensors  of  the  wrist  and  fingers  by  the 
sixth  and  seventh ;  and  those  for  the  flexors  by  the 
eighth  and  first  dorsal.  _  It  is  important  to  remem- 
ber that  a  cervical  spinal  nerve  makes  its  exit 
from  the  canal  opposite  the  origin  of  the  next 
spinal  nerve.  Further,  the  nerve  to  each  muscle 
is  made  up  of  fibres  derived  from  two  or  more 
spinal  nerves. 

The  following  is  Dr.  Herringham's  account  of 
the  usual  spinal  origin  of  the  fibres  in  the  nerves 
of  the  upper  limb,  and  of  the  usual  supply  of  the 
chief  muscles.  (The  figures  indicate  the  fifth, 
sixth,  seventh,  and  eighth  cervical  nerves,  and  the 
first  dorsal  nerve.) 

Nerves. — Nerve  of  Bell,  5,  6,  7 ;  suprascapular, 
5  or  5,  6;  external  cutaneous,  5,  6,  7;  internal 
cutaneous,  1  or  8,  1 ;  nerve  of  Wrisberg,  1 ;  circum- 
flex, 5,  6 ;  median,  6,  7,  8,  1 ;  ulnar,  8,  1 ;  musculo- 
spiral,  6,  7,  8,  or  5,  6,  7,  8. 


Chap.  XV]        THE   WRIST   AND    HAND 


315 


V 


->.     1 


/ 


3  \ 


5\\ 


\\6 


IP 


6  Irl 


Fig.  54.  —  Cutaneous 
nerve  supply  of 
upper  limb. 


Anterior  aspect:  l,  Cervical  plexus;  2,  circumflex;  3,  ext,  cut.  of  muse,  spiral; 

4,  ext.  cutaneous  ;  o,  median  ;  6,  ulnar  ;  7,  int.  cutaneous  ;  8,  n.  of  Wrisberg. 
I'v.itt-rinr  aspect:  1,  Cervical  plexus;  2,  circumflex;   3,  int.  cut.  of  muse,  spiral; 

4,  intercosto-humeral ;  5,  u.  of  Wrisberg ;  6,  int.  cutaneous;  7.  ext.  cut.  oi 

muse,  spiral ;  8,  ext.  cutaneous  ;  9,  uluar  ;  10,  radial. 


316  SURGICAL    APPLIED   ANATOMY      [Part  III 

Muscles. — 3,  4,  5,  lev.  anguli  scap. ;  5,  rhom- 
boids; 5  or  5,  6,  biceps,  brachialis  ant.,  supra- 
and  inf  ra-spinatus,  teres  minor ;  5,  6,  deltoid,  sub- 
scapulars; 6,  teres  major,  pronator  teres,  flexor 
carpi  rad.,  supin.  longus  and  brevis,  superficial 
thenar  muscles;  5,  6,  7,  serratus  magnus;  6  or  7, 
extensores  carpi  rad. ;  7,  coraco-brachialis,  latiss. 
dorsi,  extensors  at  back  of  forearm,  outer  head 
of  triceps;  7,  8,  inner  head  of  triceps;  7,  8,  1, 
flexor  sublimis,  flexores  profund.,  carpi  uln., 
long,  poll.,  pronator  quad.  ;  8,  long  head  of  tri- 
ceps, hypothenar  muscles,  interossei,  deep  thenar 
muscles. 

In  the  cutaneous  nerve  supply  of  the  fingers, 
it  must  be  remembered  that  on  the  palmar  aspect 
the  thumb,  the  two  outer  fingers,  and  the  radial 
side  of  the  ring  linger  are  supplied  by  the  median, 
the  remaining  one  and  a  half  fingers  by  the  ulnar 
(Fig.  54).  On  the  dorsal  aspect,  the  thumb  is 
supplied  by  the  radial ;  the  index  and  middle 
fingers  are  supplied  (as  far  as  the  base  of  the 
second  phalanx)  by  the  radial,  and  over  the 
second  and  third  phalanges  by  the  median.  The 
little  finger  and  the  ulnar  side  of  the  ring  finger 
are  supplied  by  the  ulnar.  The  radial  side  of 
the  ring  finger,  as  far  as  the  base  of  the  second 
phalanx,  is  supplied  by  the  radial,  and  the  rest  of 
this  side  of  the  digit  by  the  median  (Fig.  54). 
The  cleft  between  the  middle  and  ring  fingers  is 
occasionally  supplied  by  the  ulnar,  or  partly  by 
the  ulnar  and  partly  by  the  radial.  The  roots 
and  spinal  segments  to  which  these  nerves  belong 
may  be  ascertained  from  Fig.  54a.  The  roots  are 
distributed  in  order  of  origin,  the  fifth  cervical 
beginning  on  the  radial  or  outer  side  of  the 
shoulder  and  the  second  dorsal,  or  sometimes  the 
third,  ending  on  the  ulnar  or  inner  aspect  of  the 
upper  arm.  The  hand  is  mainly  supplied  by  the 
seventh.  The  neighbouring  spinal  nerves,  as  is  also 
the  case  with  ordinary  terminal  branches,  overlap 
widely  in  their  distribution.  The  area  of  anaes- 
thesia is  much  less  than   the  area  of  anatomical 


Chap.  XV]        THE    WRIST    AND    HAND 


D.lll' 


Fig.  54a.    Showing  the  sensory  distribution  of  the  spinal  nerves  in  the 

upper  limb. 
The  dotted  lines  indicate  approximately  the  area  of  each  nerve.    No  attempt  is 
made  to  show  the  extent  bo  which  the  root  areas  overlap.    (For  the  nerves 
supplying  each  area  see  Fig.  54.) 


318  SURGICAL    APPLIED    ANATOMY      [Part  III 

distribution.  The  nerves  along  the  ulnar  side  of 
the  arm  are  derived  from  cord  segments  which 
also  give  off  sympathetic  (sensory)  nerves  to  the 
heart ;  in  angina  pectoris  the  heart  is  really^  the 
cause  of  the  pain,  but  the  patient  feels  it  on,  'and 
refers  it  to,  the  ulnar  side  of  the  arm. 

Paralysis  of  the  muscnlo-spiral  nerve.— 
When  complete,  the  hand  is  flexed  and  hangs 
flaccid  ("  drop  wrist  "),  and  neither  the  wrist  nor 
the  fingers  can  be  extended.  The  latter  are  bent 
and  cover  the  thumb,  which  is  also  flexed  and 
adducted.  When  attempts  are  made  to  extend 
the  fingers,  the  interossei  and  lumbricales  alone 
act,  producing  extension  of  the  two  distal 
phalanges  and  flexion  of  the  proximal.  Supina- 
tion is  lost,  especially  if  the  elbow  be  extended 
so  as  to  exclude  the  action  of  the  biceps  muscle. 
Extension  at  the  elbow  is  lost,  but  there  is  practi- 
cally no  loss  of  sensation  unless  the  nerve  is  cut 
above  the  origin  of  its  cutaneous  branches.  Sec- 
tion of  the  radial  nerve  in  the  upper  part  of 
the  forearm  gives  no  loss  of  sensation  (Head  and 
Sherren). 

Paralysis  of  the  median  nerve.— Flexion 
of  the  middle  phalanx  is  impossible  in  every 
finger,  as  is  also  a  like  movement  of  the  distal 
joint  of  the  index  and  middle  fingers.  Partial 
flexion  of  the  distal  phalanges  of  the  two  inner 
digits  is  possible,  the  inner  part  of  the  flexor  pro- 
fundus being  supplied  by  the  ulnar  nerve. 
Flexion  of  the  proximal  phalanx  with  extension 
of  the  second  and  third  can  still  be  performed 
in  all  the  fingers  by  the  interossei.  The  thumb 
is  extended  and  adducted,  and  can  neither  be 
flexed  nor  opposed.  Bending  of  the  wrist  is  only 
possible  when  the  hand  is  forcibly  adducted  by 
means  of  the  flexor  carpi  ulnaris,  which  is  not 
paralysed.     Pronation   is   lost. 

Section  of  the  median  or  ulnar  nerves 
at  the  wrist  does  not  give  rise  to  the  results 
which  one  would  expect  from  their  anatomical 
distribution.     Such  lesions  have  been  recently  in- 


Chap.  XV]         THE    WRIST    AND    HAND 


319 


vestigated  by  Head  and  Sherren.  After  section 
of  the  ulnar  nerve  in  the  forearm — taking  this 
nerve  as  an  example  to  explain  their  obseryations 
on  nerves  generally — they  found  that  a  certain  form 
of  sensibility,  which  they  name  epicritic,  is  lost 
over  the  area  of  anatomical  distribution  /Fig.  55). 
Over  this  area  the  patient  is  unable  to  distinguish 
light  touch  (tested  by  cotton  wool)  and  degrees 
of  temperature  between  22°-40°  C.  In  a  small 
area  of  the  fifth  digit  (see  Fig.  55)  neither  pricks, 
very  coM  nor  very  hot  things  can  be  felt ;  in  this 
area,    besides    epicritic    sensibility,    there    is   also 


A 


B 


Fig.  55. — Results  of  section  of  the  ulnar  nerve  (a,  b),  and  of  the  median 
nerve  (c,  d).     (Head  and  Sherren.) 

Black:  Area  in  which  epicritic  and  protopathic  sensibilities  are  lost. 
Stippled  :  Area  in  which  only  epicritic  sensibility  is  lost. 


lost  another  form  which  they  name  protopathic. 
But  everywhere  over  the  area  of  the  ulnar  nerve 
deep  pressure  is  felt ;  deep  sensibility  remains 
because  the  nerves  which  subserve  it  arise  in  the 
forearm  and  reach  the  fingers  by  the  tendons. 
If  the  tendons  are  cut,  deep  sensibility  also  is 
lost.  The  effect  of  cutting  any  nerve  depends  on 
the  nature  of  the  fibres  it  contains ;  a  nerve  may 
contain  epicritic  fibres  for  a  small  area  and  proto- 
pathic for  a  much  wider,   or  vice  versa. 

Paralysis  of  the  ulnar  nerve.— Ulnar  flexion 
and  adduction  of  the  hand  are  limited.  Com- 
plete flexion  of  the  two  inner  fingers  is  impossible. 
The   little   finger   can   scarcely   be   moved   at   all. 


320  SURGICAL    APPLIED    ANATOMY      [Part  III 

The  action  of  the  interossei  and  two  inner  lum- 
bricales  is  lost.  The  patient  is  unable  to  adduct 
the  thumb. 

In  testing  for  paralysis  of  muscles  in  the  hand 
it  is  extremely  important  to  observe  closely  the 
muscles  which  flex,  extend,  abduct,  and  adduct 
the  thumb.  The  ulnar  border  of  the  metacarpal 
of  the  thumb  can  be  approximated  to  the  radial 
border  of  the  corresponding  bone  of  the  index 
finger  by  only  two  muscles — the  adductor  pollicis 
and  first  dorsal  interosseus.  These  are  paralysed 
when  the  ulnar  nerve  is  cut.  Their  action  may 
be  simulated  by  the  flexor  longus  pollicis,  brevis 
pollicis,  or  opponens  pollicis,  but  in  such  cases  it 
will  be  observed  that  it  is  not  the  ulnar  border 
but  the  flexor  surface  of  the  thumb  which  is  moved 
towards  the  metacarpal  bone  of  the  index  finger. 

Epiphyses  of  the  upper  limb. — The  epi- 
physes about  the  elbow  join  the  shafts  of  their 
respective  bones  at  17  years  (except  the  tip  of  the 
internal  condyle,  which  joins  at  18).  *  The  epi- 
physes at  the  shoulder  and  wrist  extremities  of 
the  bones  join  at  20.  The  nutrient  canals  of  the 
three  bones  run  towards  the  elbow.  The  nutrient 
artery  of  the  humerus  comes  from  the  brachial 
or  inferior  profunda,  those  of  the  radius  and 
ulna  from  the  anterior  interosseous. 

The  nerve  supplying  the  humerus  is  the  mus- 
culocutaneous. The  radius  and  ulna  are  sup- 
plied by  the  anterior  interosseous  of  the  median. 
It  may  be  taken  as  a  general  law  that  the  nerve 
supply  of  a  bone  is  the  same  as  that  of  the  muscles 
which   are   attached  to   it. 


Fart   IV.— THE   ABDOMEN    AND 
PELVIS 

CHAPTER    XVI 

THE    ABDOMEN 

The  abdominal  parietes. — Surface  anatomy. 
The  degree  of  prominence  of  the  abdomen  varies 
greatly.  The  protuberance  of  the  belly  in  young 
children  is  mainly  due  to  the  relatively  large  size 
of  the  liver,  which  occupies  a  considerable  part 
of  the  cavity  in  early  life.  It  also  depends  upon 
the  small  size  of  the  pelvis,  which  is  not  only 
unable  to  accommodate  any  abdominal  structure 
(strictly  so  called),  but  can  scarcely  provide  room 
for  the  pelvic  organs  themselves.  Thus  in  in- 
fancy the  bladder  and  a  great  part  of  the  rectum 
are  virtually  abdominal  viscera.  After  long- 
continued  distension,  as,  for  example,  after  preg- 
nancy, ascites,  etc..  the  abdomen  usually  remains 
unduly  prominent  and  pendulous. 

In  cases  of  great  emaciation  it  becomes  much 
sunken,  and  its  anterior  wall  appears  to  have 
collapsed.  This  change  is  most  conspicuous  about 
the  upper  part  of  the  region.  Here  the  anterior 
parietes  immediately  below  the  line  of  the  costal 
cartilages,  instead  of  being  in  the  same  plane  with 
the  anterior  thoracic  wall,  may  so  sink  in  as  to 
be  almost  at  right  angles  with  that  wall  on  the 
one  hand,  and  with  the  lower  part  of  the  ab- 
dominal parietes  on  the  other.  In  such  cases  the 
abdominal  walls  just  below  the  thoracic  line  may 
appear  to  be  almost  vertical  when  the  patient  is 
v  321 


322  SURGICAL    APPLIED    ANATOMY   [Part  IV 

in  the  recumbent  posture.  This  change  of  sur- 
face is  of  importance  in  gastrostomy,  since  the 
subjects  for  that  operation  are  usually  much 
emaciated,  and  the  incision  has  to  be  made  close 
below  the  costal  line. 

The  position  of  the  linea  alba  above  the  um- 
bilicus is  indicated  by  a  slight  median  groove, 
but  no  such  indication  exists  below  the  navel. 
The  linea  semilunaris  may  be  represented  by  a 
slightly  curved  line  drawn  from  about  the  tip  of 
the  ninth  costal  cartilage  to  the  pubic  spine. 
In  the  adult  it  would  be  placed  about  3  inches 
from  the  navel.  Above  the  umbilicus  the  line  is 
indicated  on  the  surface  by  a  shallow  depression. 
The  outline  of  the  rectus  can  be  well  seen  when  the 
muscle  is  in  action.  It  presents  three  "  linear 
transversa,"  one  usually  opposite  the  xiphoid 
cartilage,  one  opposite  the  umbilicus,  and  a  third 
between  the  two.  The  two  upper  of  these  lines 
are  obvious  on  the  surface  in  well-developed  sub- 
jects. 

The  site  of  the  umbilicus  varies  with  the 
obesity  of  the  individual  and  the  laxity  of  the 
abdomen.  It  is  always  below  the  centre  of  the 
line  between  the  xiphoid  cartilage  and  the  pubes. 
In  the  adult  it  is  some  way  above  the  centre  of  the 
body,  as  measured  from  head  to  foot,  while  in 
the  foetus  at  birth  it  is  below  that  point.  It  corre- 
sponds in  front  to  the  disc  between  the  third  and 
fourth  lumbar  vertebrae,  and  behind  to  the  tip  of 
the  third  lumbar  spinous  process.  It  is  situated 
about  |  of  an  inch  above  a  line  drawn  between  the 
highest  points  of  the  two  iliac  crests. 

The  anterior  superior  spine,  the  pubic  spine, 
and  Poupart's  ligament  are  all  conspicuous  and 
important  landmarks.  The  pubic  spine  is  nearly 
in  the  same  horizontal  line  as  the  upper  edge  of 
the  great  trochanter.  It  is  very  distinct  in  thin 
subjects.  In  the  obese  it  is  entirely  lost  beneath 
the  pubic  fat.  In  such  individuals,  however,  it 
can  be  detected,  when  the  subject  is  a  male,  by 
invaginating  the  scrotum  so  as  to  pass  the  finger 


Chap.  XVI]  THE    ABDOMEN  323 

beneath  the  subcutaneous  fat.  In  the  female  the 
position  of  the  process  may  be  made  out  by  ad- 
ducting  the  thigh  and  thus  making  prominent 
the  tendon  of  origin  of  the  adductor  longus  mus- 
cle. This  muscle  arises  from  the  body  of  the 
pubes  immediately  below  the  spine,  and  by  run- 
ning the  finger  along  the  muscle  the  bony  promi- 
nence may  be  reached.  If  the  finger  be  placed 
upon  the  pubic  spine  it  may  be  said  that  a  hernia 
descending  to  the  inner  side  of  the  finger  will  be 
inguinal,  while  one  presenting  to  the  outer  side 
will  be  femoral.  In  the  erect  position  of  the  body 
the  anterior  superior  spine  is  a  little  below  the 
level  of  the  promontory  of  the  sacrum,  while  a 
point  taken  over  the  junction  of  sternum  and 
ensiform  process — the  sterno-ensiform  point — is 
opposite  the  upper  part  of  the  tenth  dorsal  ver- 
tebra. This  point  can  be  readily  recognised  in 
even  fat  subjects  by  the  depression  below  the 
sternal  insertions  of  the  seventh  pair  of  costal 
cartilages,  and,  as  will  be  seen  presently,  forms 
a  valuable  landmark.  A  point  taken  midway  be- 
tween the  umbilicus  and  sterno-ensiform — the 
mid-epigastric  point — lies  opposite  the  disc  be- 
tween the  first  and  second  lumbar  vertebrae  and  is 
a  surface  marking  of  great  clinical  utility 
(Addison). 

In  that  part  of  the  back  which  corresponds  to 
the  abdominal  region  the  erector  spinse  masses 
are  distinct,  and  in  any  but  fat  subjects  their 
outer  edges  can  be  well  defined.  Between  these 
masses  is  the  spinal  furrow,  which  ends  below  in 
an  angle  formed  by  the  two  great  gluteal  muscles. 
Immediately  behind  the  middle  of  the  crest  of  the 
ilium  is  Petit's  triangle,  or  the  gap  between  the 
external  oblique  and  latissimus  dorsi  muscles. 
The  fourth  lumbar  spine  is  about  on -a  level  with 
the  highest  part  of  the  iliac  crest.  In  counting 
the  ribs  it  is  well  to  commence  from  above,  since 
the  last  rib  may  not  project  beyond  the  outer 
edge  of  the  erector  spinse,  and  may  consequently 
be  overlooked. 


324  SURGICAL    APPLIED    ANATOMY   [Part  IV 

The  aorta  bifurcates  opposite  the  middle  of  the 
body  of  the  fourth  lumbar  vertebra  just  to  the 
left  of  the  middle  line  about  |  of  an  inch  below 
and  to  the  left  of  the  umbilicus.  A  line  drawn 
on  either  side  from  the  point  of  bifurcation  to  the 
middle  of  Poupart's  ligament  will  correspond  to 
the  course  of  the  common  and  external  iliac 
arteries.  The  first  two  inches  of  this  line  would 
cover  the  common  iliac,  the  remainder  the  ex- 
ternal. 

The  coeliac  axis  comes  off  opposite  the  lower 
part  of  the  twelfth  dorsal  vertebra,  at  a  spot 
about  lh  inch  above  the  mid-epigastric  point, 
and  that  corresponds  behind  to  the  twelfth  dorsal 
spine.  The  superior  mesenteric  and  suprarenal 
arteries  are  just  below  the  axis.  The  renal  vessels 
arise  about  ^  an  inch  below  the  superior  mesen- 
teric, opposite  the  mid-epigastric  point.  The  in- 
ferior mesenteric  artery  comes  off  from  the  aorta 
about  1  inch  above  the  umbilicus.  The  deep  epi- 
gastric artery  follows  a  line  drawn  from  the 
middle  of  Poupart's  ligament  to  the  umbilicus. 
Along  the  same  line  may  sometimes  be  seen  the 
superficial  epigastric  vein. 

The  abdominal  "  rings  "  will  be  referred  to 
under  Hernia  (p.  339). 

Anterior  abdominal  parietes.— The  si- in 
over  the  front  of  the  abdomen  is  loosely  attached 
in  the  region  of  the  groin.  It  is  more  adherent  to 
the  deeper  parts  in  the  middle  line  than  else- 
where, but  not  so  adherent  as  to  hinder  the  spread 
of  inflammation  from  one  side  of  the  abdomen  to 
the  other.  In  cases  of  great  obesity  two  transverse 
creases  form  across  the  belly,  one  crossing  the 
umbilicus  and  the  other  passing  just  above  the 
pubes.  In  the  former  of  the  two  creases  the  navel 
is  usually  hidden  from  sight.  In  cases  of  anky- 
losed  hip-joints  transverse  creases  are  often  noted 
running  across  the  middle  of  the  belly.  They  are 
produced  by  the  freer  bending  of  the  spine  that 
is  usually  required  in  ankylosis,  some  of  the 
simpler  movements  of  the  hip-joint  being  trans- 


Chap.  XVII  THE    ABDOMEN  325 

ferred  to  the  column  when  the  articulation  is 
rendered  useless. 

After  the  skin  has  been  stretched,  from  any 
gross  distension  of  the  abdomen,  certain  silvery 
streaks  appear  in  the  integument  over  its  lower 
part.  They  are  due  to  an  atrophy  of  the  skin 
produced  by  the  stretching,  and  their  position 
serves  to  indicate  the  parts  of  the  parietes  upon 
which  distending  forces  within  the  abdomen  act 
most  vigorously.  They  are  well  seen  after  preg- 
nancy, ascites,  ovarian  tumours,  etc. 

Beneath  the  skin  is  the  superficial  fascia,  which 
over  the  lower  half  of  the  abdomen  can  be  readily 
divided  into  two  layers.  The  great  bulk  of  the 
subcutaneous  fat  of  this  region  is  lodged  in  the 
more  superficial  of  the  two  layers.  In  cases  of 
great  obesity  the  accumulation  of  fat  is  perhaps 
more  marked  beneath  the  skin  of  the  abdomen 
than  it  is  elsewhere.  A  layer  of  fat  6  inches  in 
depth  has  been  found  in  this  region  in  cases  of 
great  corpulence.  The  superficial  vessels  and  nerves 
lie  for  the  most  part  between  the  two  layers  of  the 
fascia,  so  that  in  obese  subjects  incisions  may  be 
made  over  the  abdomen  to  the  depth  of  an  inch  or 
so  without  encountering  blood-vessels  of  any 
magnitude. 

The  deep  layer  of  the  superficial  fascia  con- 
tains elastic  fibres,  and  corresponds  to  the  tunica 
abdominalis  or  "  abdominal  belt "  of  animals. 
It  is  attached  to  the  deeper  parts  along  the  middle 
line  as  far  as  the  symphysis,  and  to  the  fascia 
lata  just  beyond  Poupart's  ligament.  In  the  in- 
terval between  the  symphysis  and  the  pubic  spine 
it  has  no  attachment,  but  passes  down  into  the 
scrotum  and  becomes  the  dartos  tissue.  Extrava- 
sated  urine  that  has  reached  the  scrotum  may 
mount  up  on  to  the  abdomen  through  this  in- 
terval, and  will  then  be  limited  by  the  deeper 
layer  of  the  fascia.  It  will  not  be  able  to  pass 
down  into  the  thigh  on  account  of  the  attachments 
of  the  fascia,  nor,  for  a  like  reason,  will  it  tend 
to  pass  over  the  middle  line.     In  the  same  way 


326  SURGICAL    APPLIED    ANATOMY  [Part  IV 

emphysematous  collections  following  injuries  to 
the  chest,  when  beneath  the  deeper  layer  of  the 
fascia,  receive  a  check  at  the  groin,  and  lipomata 
also  that  grow  beneath  the  membrane  tend  to  be 
limited  by  the  middle  line  and  that  of  Poupart's 
ligament. 

The  anterior  abdominal  parietes  vary  in  thick- 
ness in  different  subjects.  In  cases  of  great 
emaciation  the  outlines  of  some  of  the  viscera  may 
be  readily  made  out  or  even  seen  through  the 
thinned  wall.  In  some  cases  of  chronic  intestinal 
obstruction  the  outlines  of  the  distended  intestine 
are  visible,  and  their  movements  can  be  watched ; 
in  instances  of  obstruction  of  the  pylorus  the 
movements  of  the  dilated  and  hypertrophied 
stomach  can  often  be  seen.  The  relative  thickness 
of  the  abdominal  wall  in  various  subjects  depends 
rather  upon  the  amount  of  the  subcutaneous  fat 
than  upon  the  thickness  of  the  muscles.  This 
muscular  boundary  affords  an  admirable  protec- 
tion to  the  viscera  within.  By  contracting  the 
abdominal  muscles  the  front  of  the  belly  can  be 
made  as  hard  as  a  board,  and  in  acute  peritonitis 
this  contraction  can  sometimes  be  seen  to  produce 
a  remarkable  degree  of  rigidity. 

A  blow  upon  the  abdomen  when  the  muscles 
are  firmly  contracted  will  probably  do  no  injury 
to' the  viscera  unless  the  violence  be  extreme.  The 
rigid  muscular  wall  acts  with  the  efficacy  of  a 
dense  indiarubber  plate.  It  may  be  bruised  or 
torn,  but  it  will  itself  receive  the  main  shock  of 
the   contusion. 

The  probable  effect  on  the  contained  viscera 
of  a  blow  upon  the  abdomen  will  depend  upon 
many  factors ;  but,  so  far  as  the  walls  themselves 
are  concerned,  the  effect  greatly  depends  upon 
whether  the  blow  was  anticipated  or  not,  and 
upon  the  extent  of  the  padding  of  fat  that  is  fur- 
nished to  the  parietes.  If  the  blow  be  anticipated 
the  muscles  of  the  belly  will  be  instinctively 
contracted,  and  the  viscera  at  once  provided 
with   a   firm   but   elastic   shield.     Thus   the   abdo- 


Chap.  XVI]  THE    ABDOMEN  327 

minal  muscles  have  been  found  bruised  and  torn 
while  the  viscera  were  intact,  and,  on  the  other 
hand,  in  cases  probably  where  the  muscles  were 
inert  or  taken  unawares,  a  viscus  has  been  found 
to  be  damaged  without  there  being  any  con- 
spicuous lesion  in  the  belly  wall.  If  the  blow  be 
anticipated  also  the  body  will  probably  be  abruptly 
bent  and  the  viscera  be — as  it  were — removed  from 
danger. 

Along  the  linea  alba  the  abdominal  wall  is 
thin,  dense,  and  free  from  visible  blood-vessels. 
Hence  in  many  operations  upon  the  abdominal 
cavity  the  incision  is  made  in  the  middle  line. 
Along  the  outer  border  of  the  rectus  muscle  {i.e. 
about  and  just  beyond  the  linea  semilunaris)  the 
parietes  are  also  thin  and  lacking  in  vessels,  and 
consequently  that  situation  is  well  suited  for  an 
incision.  Except  in  some  operations  on  the 
kidney,  stomach,  or  gall  bladder,  incisions  are 
seldom  so  placed.  In  most  cases  it  is  a  question 
of  either  opening  the  abdomen  in  the  middle  line 
or  in  one  of  the  iliac  regions.  About  1  inch 
below  the  navel  the  two  recti  muscles  are  almost  in 
contact,  and  here  the  linea  alba  can  scarcely  be 
said  to  exist,  while  above,  the  muscles  remain 
apart,  the  linea  alba  being  normally  f  of  an  inch 
wide.  In  pregnancy,  obesity,  and  ascites  the  supra- 
umbilical  part  may  become  2  or  more  inches  wide, 
but  the  narrow  infraumbilical  part  is  unaffected; 
when  this  part  of  the  linea  alba  widens  the  con- 
dition is  known  as  divarication  of  the  recti. 
When  this  is  the  case  the  contents  of  the  abdomen 
bulge  out  between  the  recti  when  these  two  muscles 
are  thrown  into  action,  as  when  a  patient  at- 
tempts to  assume  the  sitting  from  a  supine 
posture  unaided  by  the  arms.  Pellets  of  sub- 
peritoneal fat  may  grow  through  interstices  in 
the  linea  alba  and  give  rise  to  what  are  called 
"  fatty  hernise." 

The  fibrous  ring  of  the  umbilicus  is  derived 
from  the  linea  alba.  To  this  ring  the  adjacent 
structures,   skin,   fascia,   and  peritoneum,   are  all 


328  SURGICAL    APPLIED    ANATOMY   [Part  IV 

closely  adherent.  The  adhesion  is  such,  and  the 
amount  of  tissue  between  the  skin  and  peritoneum 
is  so  scanty,  that  in  operating  upon  an  umbilical 
hernia  it  is  scarcely  possible  to  avoid  opening  the 
sac. 

The  umbilicus  represents  the  point  where  the 
lateral  abdominal  walls  finally  close.  At  the 
sixth  week  the  opening  is  funnel-shaped  and  con- 
tains the  yolk  sac  and  a  fold  of  the  bowel  to  which 
it  is  attached.  This  condition  may  persist  and 
give  rise  to  a  congenital  umbilical  hernia.  In 
the  foetus  three  vessels  enter  at  the  navel,  and 
immediately  separate  on  reaching  the  abdominal 
cavity,  the  vein  passing  directly  upwards  and  the 
arteries  obliquely  downwards.  Running  down 
from  the  umbilicus  in  the  middle  line  is  also  the 
remains  of  the  urachus.  In  the  foetus,  the  spot 
where  the  three  vessels  part  company  is  about  the 
centre  of  the  navel,  and  it  thus  happens  that  in  a 
congenital  umbilical  hernia  the  gut  as  it  escapes 
separates  the  three  vessels,  which  become  to  some 
extent  spread  over  it.  The  congenital  hernia,  in- 
deed, works  its  way  in  among  the  structures  of 
the  cord  and  receives  its  main  coverings  from 
them.  These  hernise  are  fortunately  rare,  for  in 
certain  instances  they  extend  some  way  into  the 
cord,  and  in  at  least  two  reported  cases  the  gut 
was  cut  across  by  the  accoucheur  in  dividing  the 
cord  at  birth.*  As  the  abdomen  increases  in 
height  the  contraction  of  the  two  obliterated 
arteries  and  of  the  urachus  drags  upon  the  cica- 
trix and  pulls  it  backwards  and  downwards. 
Thus,  in  the  adult  umbilical  ring,  as  viewed  from 
the  inner  side,  the  cords  representing  not  only  the 
obliterated  arteries  and  the  urachus,  but  also  the 
vein,  appear  to  start  from  the  lower  border  of 
the  cicatrix.  In  adult  hernise,  indeed,  the  gut 
escapes  above  both  the  obliterated  arteries  and 
the  vein.     The  upper  half  of  the  cicatrix  is  thin 

*  The  congenital  hernia  must  be  distinguished  from  the  infantile 
umbilical  hernia  so  commonly  met  with  after  separation  of  the  cord.  For 
an  account  of  these  congenital  hernia*.,  see  paper  by  the  Author  in  the 
Lancet,  vol.  i.,  1881,  p.  323. 


Chap.  XVI]  THE    ABDOMEN  329 

when  compared  to  the  lower  half,  and  is  sup- 
ported also  by  less  firm  adhesions. 

In  some  cases  a  fistula  is  found  at  the  navel 
that  discharges  urine.  This  is  due  to  a  patent 
urachus.  The  urinary  bladder  is  formed  by  a 
dilatation  of  the  stalk  of  the  allantois.  The  part 
below  this  dilatation  becomes  the  first  part  of 
the  urethra,  that  above  becomes  the  urachus.  In 
one  instance  of  patent  urachus  the  abnormal  open- 
ing was  1  inch  in  diameter.  The  patient,  a  man 
aged  40,  had  a  stone,  which  was  extracted  by 
passing  the  finger  into  the  bladder  through  the 
opening  at  the  umbilicus. 

Sometimes  a  fistula  discharging  faeces  is  met 
with  at  the  navel.  This  depends  upon  the  per- 
sistence of  the  vitello-intestinal  duct,  a  duct  that 
at  one  time  connects  the  intestine  of  the  early 
foetus  with  the  yolk  sac,  and  which  generally  dis- 
appears without  leaving  any  trace.  The  per- 
sistent duct,  when  it  occurs,  is  known  as  Meckel's 
diverticulum,  and  springs  from  the  ileum  some 
two  or  more  feet  above  the  ileo-csecal  orifice. 
This  fcetal  relationship  also  explains  the  presence 
of  a  fibrous  cord  which  is  sometimes  seen  con- 
necting Meckel's  diverticulum  with  the  umbilicus. 
This  fibrous  cord  may  cause  strangulation  of  the 
bowel. 

The  position  of  the  transverse  intersections  of 
the  rectus  muscle  should  be  borne  in  mind. 
They  adhere  to  the  anterior  layer  of  the  rectus 
sheath,  but  not  to  the  posterior.  They  are  able, 
therefore,  to  some  extent  to  limit  suppurative 
collections  and  haemorrhages  beneath  the  sheath 
on  its  anterior  aspect.  This  muscle  is  often  the 
seat  of  one  form  of  "  phantom  tumour. ;;  These 
tumours  are  mostly  met  with  in  the  hysterical 
and  hypochondriac,  and  when  associated  with 
some  vague  abdominal  symptoms  are  apt  to  mis- 
lead. They  are  due  to  a  partial  contraction  of 
the  muscle,  usually  to  a  part  between  two  inter- 
sections, and  are  said  to  be  more  common  in  the 
upper  part  of  the  rectus.     When  the  fibres  of  the 


330  SURGICAL    APPLIED    ANATOMY  [Part  IV 

muscle  are  contracted  the  "  tumour  "  is  obvious, 
but  when  they  relax  it  disappears.  The  phantom 
tumour,  however,  is  not  always  a  matter  of  little 
moment.  It  may  be  associated  with  grave  disease 
within  the  abdomen,  and  be  due  to  reflex  muscular 
contraction,  the  starting  point  of  such  reflex  act 
being  in  the  viscera.  These  localised  contractions 
may  provide  a  clue  to  the  seat  of  visceral  disease. 
Thus  the  stomach  derives  its  chief  sensory  nerve 
supply  from  the  eighth  dorsal  segment  of  the 
cord;  the  section  of  the  rectus  between  the  upper 
and  middle  inscriptions  is  also  supplied  from 
this  segment  through  the  eighth  dorsal  nerve ; 
hence  contraction  of  this  section  may  be  asso- 
ciated with  disease  of  the  stomach.  The  rectus 
receives  nerves  from  the  lower  six  dorsal  nerves ; 
the  section  at  the  umbilicus  is  supplied  by  the 
tenth. 

I  have,  for  example,  seen  a  conspicuous  phan- 
tom tumour  in  the  upper  part  of  the  right  rectus 
associated  with  cancer  of  the  stomach,  with  ulcer 
of  the  duodenum,  and  with  malignant  disease  of 
the  peritoneum. 

Other  vanishing  tumours  depend  upon  disten- 
sion of  the  intestines  by  flatus  or  by  faecal 
matter.  In  great  distension  of  the  abdomen  the 
fibres  of  the  rectus  may  be  much  stretched,  since 
they  bear  the  brunt  of  the  distending  force. 
The  direction  of  the  fibres  also  renders  them 
liable  to  be  torn  in  opisthotonos,  or  extreme  arch- 
ing of  the  back,  or  tetanus.  Portions  of  the  muscle 
have  also  been  ruptured  by  muscular  violence,  as 
in  vaulting. 

The  lateral  muscles  of  the  front  abdominal 
wall  are  separated  from  one  another  by  layers 
of  loose  connective  tissue.  In  the  tissue  between 
the  internal  oblique  and  transversalis  are  found 
the  chief  nerves  and  arteries. 

Everywhere  the  peritoneum  is  bound  to  the 
abdominal  wall  by  subperitoneal  connective 
tissue.  In  the  pelvis  this  tissue  is  lax  to  allow 
the    viscera   of    the    pelvis — the    bladder,    rectum, 


Chap.  XVI]  THE    ABDOMEN  331 

and  uterus — to  expand;  so,  too,  over  the  iliac 
fossae  and  on  the  anterior  abdominal  wall  for 
two  inches  above  Poupart's  ligament  and  the 
symphysis  pubis ;  but  above  this  level  and  on 
the  under  surface  of  the  diaphragm  it  binds  the 
peritoneum  down  closely.  The  looseness  of  this 
layer  greatly  favours  the  spread  of  abscess,  to 
the  progress  of  which  it  offers  little  resistance. 
Such  an  abscess  may  spread  from  the  viscera, 
especially  from  those  that  have  an  imperfect 
peritoneal  covering,  as,  for  example,  the  kidney, 
the  vertical  parts  of  the  colon,  etc.  The  laxity 
of  this  tissue  has  been  of  service  in  certain 
surgical  procedures.  Thus  the  external  and 
common  iliac  arteries  can  be  reached  by  an  in- 
cision made  some  way  to  the  outer  side  of  the 
vessels  and  without  opening  the  peritoneum. 
That  membrane  having  been  exposed  in  the 
lateral  wound,  the  artery  is  reached  by  working 
a  way  with  the  finger  through  the  subperitoneal 
tissue,  and  by  actually  stripping  the  serous  mem- 
brane from  its  attachments.  Ligature  of  the 
iliac  vessels  at  the  present  day  is  usually  effected 
through  a  direct  incision  which  opens  the  peri- 
toneal cavity.  The  method  just  detailed  belongs 
to  pre-antiseptic  days.  The  laxity  of  the  sub- 
serous layer  also  favours  that  stretching  of  the 
peritoneum  which  occurs  under  certain  circum- 
stances. 

Wounds  of  the  abdomen  may  give  trouble 
in  their  treatment,  since,  when  inflicted,  they 
may  open  up  several  layers  of  fascia  and  so  lead 
to  bagging  of  pus  and  to  the  spread  of  suppura- 
tion should  an  abscess  follow  the  lesion.  The 
constant  respiratory  movements  of  the  belly  walls 
do  not  favour  that  rest  which  is  so  essential  to 
the  healing  of  wounds.  In  penetrating  wounds 
the  contraction  of  the  muscles  may  encourage  the 
protrusion  of  the  viscera,  especially  when  the 
incision  is  transverse  to  the  direction  of  the 
muscular  fibres.  In  reducing  small  portions  of 
protruded    viscera    it    is    quite    possible    to    push 


332  SURGICAL   APPLIED    ANATOMY  [Part  IV 

them  into  one  of  the  connective  tissue  spaces  be- 
tween the  muscles  or  into  the  subserous  tissue  in- 
stead of  into  the  peritoneal  cavity.  In  applying 
sutures  to  wounds  involving  the  whole  thickness 
of  the  parietes  it  is  necessary  that  the  threads 
should  include  the  peritoneum,  so  that  early 
healing  of  that  membrane  may  be  brought  about. 
Without  such  precaution  a  gap  may  be  left  in 
the  surface  of  the  peritoneum  which  would 
favour  the  formation  of  a  hernia  in  the  site  of 
the  old  wound. 

Blood-vessels. — The  only  arteries  of  any  mag- 
nitude in  the  abdominal  walls  are  the  two 
epigastric  arteries,  some  branches  of  the  deep 
circumflex  iliac,  the  last  two  intercostal  vessels, 
the  epigastric  branch  of  the  internal  mammary, 
and  the  abdominal  divisions  of  the  lumbar 
arteries.  The  superficial  vessels  are  of  small 
size,  although  Verneuil  reports  a  case  of  fatal 
haemorrhage  from  the  superficial  epigastric 
vessel. 

The  superficial  veins  on  the  front  of  the 
abdomen  are  numerous,  and  are  very  distinct 
when  varicose.  A  lateral  vein,  extending  from 
the  axilla  to  the  groin,  uniting  the  axillary  and 
femoral  veins,  is  often  rendered  in  this  way  very 
prominent.  The  surface  abdominal  veins  may 
take  no  part  as  alternative  blood  channels  in 
cases  of  obstruction  of  the  inferior  vena  cava. 
Clinical  experience  shows  that  these  veins  may 
be  also  enormously  varicose  in  instances  where 
the  inferior  cava  is  quite  patent.  In  one  case 
under  my  care  there  was  extensive  varicosity  of 
the  surface  veins  from  the  pectoral  region  to  the 
groin  that  involved  one  side  of  the  body  only. 
It  has  been  shown,  moreover,  that  the  valves  of 
these  vessels  are  so  arranged  that  the  blood  in  the 
surface  veins  above  the  navel  goes  to  the  axilla, 
while  that  in  the  veins  of  the  subumbilical  region 
runs  to  the  groin.  In  the  neighbourhood  of  the 
umbilicus  these  veins  are  connected  with  the 
portal    vein    in    the    liver    through    anastomotic 


Chap.  XVI] 


THE    ABDOMEN 


333 


venous  channels  in  the  falciform  ligament  of  the 
liver  (Sappey). 

As  regards  the  surface  lymphatics  of  the  front 
of  the  abdomen,  it  may  be  said  in  general  terms 
that  those  above  the  umbilicus  go  to  the  axillary 


Diaphragmatic 

Cardiac 
Oesophageal 


C.A5TRIC 

Mepatic 
mtestimal 
Colic 

Vesical 
Re/nalTesticular 


Fig.  56. — Showing  approximately  the  areas   of  skin   supplied  hy   spinal 
nerves  on  the  anterior  surface  of  the  trunk. 

The  areas  are  marked  on  the  left  side  by  dotted  lines,  and  the  number  of  the 
spinal  nerve  by  which  each  is  supplied  is  indicated.  The  nerves  are  shows 
on  the  right  side.  The  red  stippled  areas  show  the  regions  to  which  pain  in 
commonly  referred  in  connection  with  visceral  disease— according  to  the 
observations  of  Dr.  .lames  Mackenzie.  The  pain  radiates  towards  the  unen- 
closed part  of  each  area. 

glands,    and    those    below    to    the    glands    of    the 
groin. 

IVerves.  —  The  abdominal  wall  is  supplied  by 
the  lowest  six  dorsal  or  intercostal  nerves,  and 
by  the  first  lumbar  nerve.  These  nerves  run 
obliquely  to  the  long  axis  of  the  abdomen  down- 
wards and  inwards  from  the  sides  to  the  middle 
line  and  hence  are  damaged  more  extensively  in 
vertical   than   in   oblique   incisions.     Their   direc- 


334  SUEGICAL    APPLIED    ANATOMY   [Part  IV 

tion  is  represented  by  a  continuation  of  the  lines 
of  the  ribs  :  they  are  placed  parallel  to  one 
another  and  at  fairly  equal  distances  apart.  It 
is  important  to  note  that  they  supply  not  only 
the  abdominal  integument,  but  also  the  muscles 
of  the  belly,  viz.,  the  rectus,  the  two  oblique 
muscles,  and  the  transversalis.  The  segments  of 
the  spinal  cord  which  supply  the  skin  also 
innervate  the  underlying  muscles,  an  association 
of  great  importance  (Fig.  56).  If  a  cold  hand 
be  suddenly  placed  upon  the  belly  the  muscles 
at  once  contract  and  the  abdomen  is  instinctively 
rendered  rigid.  The  safety  of  the  viscera,  at 
least  so  far  as  protection  from  contusions  is  con- 
cerned, depends  upon  the  readiness  with  which 
the  muscles  can  contract  at  the  first  indication 
of  danger.  As  has  been  already  stated,  the 
viscera  have  a  very  efficient  protection  against 
the  effects  of  blows  when  the  belly  muscles  are  in 
a  state  of  rigid  contraction.  The  sensitive  skin 
acts  the  part  of  a  sentinel,  and  the  intimate  asso- 
ciation of  the  surface  nerves  with  the  muscular 
nerves  allows  the  warnings  of  this  sentinel  to  be 
readily  given  and  immediately  acted  upon.  The 
rigidity  of  the  muscles  in  certain  painful  affec- 
tions of  the  skin  over  the  abdomen  is  often  very 
conspicuous.  I  might  instance  the  case  of  a 
man  with  a  burn  over  the  belly.  While  the  burn 
is  protected  by  the  dressings  the  abdominal 
muscles  are  lax  and  the  parietes  move  with  the 
respiratory  act.  The  moment  the  dressings  are 
removed,  the  surface  becoming  painful,  its  spinal 
centre  becomes  excited  and  the  muscles  at  once 
contract  and  the  belly  becomes  rigid. 

It  will  be  noticed  that  six  of  the  abdominal 
nerves  supply  intercostal  muscles,  and  are  thus 
intimately  associated  with  the  movements  of  re- 
spiration. The  abdominal  muscles  are  of  course 
-concerned!  in  the  same  movements.  These  asso- 
ciations are  illustrated  when  cold  water  is  sud- 
denly dashed  upon  the  belly.  The  subject  of 
such   experiment    at    once    experiences   a    violent 


Chap.  XVI]  THE    ABDOMEN  335 

respiratory  movement  in  the  form  of  a  deep 
gasp.  When  the  abdominal  muscles  are  firmly 
fixed  the  lower  ribs  are  also  rigid,  and  respiration 
is  limited  to  the  higher  ribs  and  to  the  thorax 
proper. 

There  are  other  practical  points  about  these 
nerves.  In  caries  of  the  spine,  and  in  certain 
injuries  to  the  column,  the  spinal  nerves  may 
suffer  injury  as  they  issue  from  the  vertebral 
canal.  This  injury  may  show  itself  by  modified 
sensation  in  the  parts  supplied  by  such  nerves. 
Thus  in  Pott's  disease  the  patient  often  com- 
plains of  a  sense  of  tightness  about  the  abdomen, 
as  if  a  cord  were  tied  around  it.  This  sense  of 
constriction  depends  upon  an  impaired  sensation 
in  the  parts  supplied  by  a  certain  pair  of  nerves ; 
or,  if  the  sense  of  constriction  be  wider  spread, 
by  two  or  more  pairs  of  nerves.  In  other  cases 
a  sense  of  pain  may  take  the  place  of  that  of 
constriction.  It  would  hardly  be  believed  that 
spinal  disease  has  been  mistaken  for  "  belly- 
ache." But  many  such  cases  have  been  recorded. 
A  child  complains  of  pain  over  the  pit  of  the 
stomach  or  about  the  umbilicus,  and  this  feature 
may  quite  absorb  for  a  while  the  surgeon's  atten- 
tion. The  abdomen  is  carefully  poulticed,  while 
the  only  mischief  is  in  the  vertebral  column. 
Other  symptoms,  however,  develop,  and  it  be- 
comes evident  that  the  pain  is  due  to  pressure 
upon  the  nerves  supplying  the  skin  over  the 
epigastric  or  umbilical  regions,  and  that  that 
pressure  is  a  circumstance  in  the  course  of  spinal 
bone  disease.  A  case  came  under  my  notice  in 
which  a  man  complained  of  intense  and  abiding 
pain  over  the  stomach.  The  pain  was  made 
worse  by  food,  and  as  all  means  used  failed  to 
relieve  it,  the  abdomen  was  opened  by  an  explor- 
atory incision.  Nothing  abnormal  was  dis- 
covered. A  little  later  it  became  evident  that 
the  pain  was  due  to  a  malignant  tumour  situated 
in  the  bodies  of  the  dorsal  vertebrae.  There  had 
never,   before  the  operation,   been   any  suspicion 


336  SURGICAL    APPLIED    ANATOMY   [Part  IV 

of  spinal  disease.  The  site  of  the  painful  part 
depends,  of  course,  upon  the  position  of  the 
spinal  ailment,  and  thus  the  cutaneous  symptoms 
may  serve  to  localise  the  caries  in  the  vertebrae. 
Thus  the  skin  over  the  "  pit  of  the  stomach  "  is 
supplied  by  the  sixth  and  seventh  dorsal  nerves, 
and  the  tenth  nerve  is  nearly  in  a  line  with  the 
umbilicus.  The  position  of  the  areas  supplied 
by  each  spinal  nerve  on  the  trunk  is  shown  in 
Fig.  56.  The  umbilicus  may  be  at  the  upper  or 
lower  border  of  the  area  of  the  tenth,  according 
to  the  individual,  A  spinal  root  may  be  cut  and 
yet  scarcely  a  trace  of  anaesthesia  result  owing 
to  the  overlapping  of  the  nerve   distributions. 

Not  only  may  a  lesion  at  the  origin  of  a  spinal 
nerve  give  rise  to  a  pain  referred  by  the  patient 
to  the  abdomen,  but,  as  may  be  readily  understood 
from  the  fact  that  the  nerves  of  the  abdominal 
wall  also  supply  the  lower  half  of  the  thorax, 
thoracic  lesions  may  also  give  rise  to  symptoms 
which  are  referred  to  the  abdomen.  Pain  or  tender 
areas  in  the  upper  part  of  the  abdomen  may  be 
actually  due  to  a  pleurisy  in  the  lower  part  of 
the  thorax. 

Although  the  course  of  the  spinal  nerves  in 
the  body  wall  is  oblique — following  the  axes  of 
the  ribs — yet  in  their  final  distribution  they  supply 
zones  of  skin  which  approximately  pass  horizont- 
ally round  the  body.  This  is  due  to  the  fact 
that  the  posterior  primary  divisions  and  lateral 
cutaneous  branches,  before  they  reach  their  areas 
of  skin,  descend  to  the  same  level  as  the  anterior 
cutaneous  nerves — the  terminal  branches  of  the 
anterior  divisions.  Indeed,  the  lateral  cutaneous 
nerves  of  the  lower  segments,  as  the  lower  limb 
is  approached,  actually  descend  further  than  the 
anterior  cutaneous  nerves  (Fig.  56).  The  hori- 
zontal arrangement  of  the  skin  areas  is  demon- 
strated bv  the  distribution  of  herpes  zoster — a 
disease  which  is  now  ascribed  to  a  lesion  of  the 
ganglia  of  the  posterior  roots. 

The   nerves  of  the  body   wall   have   still  more 


Chap.  XVI]  THE    ABDOMEN  337 

important  associations.  The  cord  segments  with 
which  they  are  connected  are  also  in  communica- 
tion with  the  viscera  of  the  abdomen  and  thorax 
through  the  sympathetic  system.  Hence  diseased 
conditions  in  the  abdominal  viscera  give  rise  to 
disturbances  in  the  corresponding  cord  segments, 
and  the  brain,  being  accustomed  to  localise  pain 
only  along  the  spinal  nerves,  makes  a  mistake  and 
refers  the  pain  along  the  spinal  nerve  of  the  seg- 
ment disturbed.  Not  only  is  pain  referred,  but 
the  skin  supplied  from  the  disturbed  spinal  seg- 
ments becomes  tender,  and  through  a  study  of 
these  areas  of  tenderness,  Head  has  been  able  to 
localise  the  visceral  centres  in  the  spinal  cord,  thus 
affording  the  surgeon  a  means  for  increased 
accuracy  of  diagnosis.  The  abdominal  viscera 
are  supplied  from  the  sixth  dorsal  to  the  first 
lumbar  spinal  segments,  the  nerves  passing  to 
their  destinations  through  the  rami  communi- 
cantes,  splanchnic  nerves  and  sympathetic 
plexuses  of  the  abdomen.  JSTo  visceral  nerves  es- 
cape by  the  second,  third,  or  fourth  lumbar 
nerve  roots,  hence  these  are  never  the  seats  of 
visceral  referred  pains.  The  pelvic  viscera  are 
supplied  from  the  fifth  lumbar  to  the  third  or 
sometimes  fourth  sacral  nerve  through  the  nervi 
erigentes. 

It  is  important  to  remember,  too,  that  there 
are  three  systems  of  nerves  in  the  belly  wall  : 
(1)  the  nerves  to  the  skin;  (2)  the  nerves  to  the 
muscles  (motor  and  sensory) ;  (3)  the  nerves  to  the 
parietal  peritoneum.  Any  one  or  all  of  these  three 
sets  may  be  the  seat  of  referred  pain,  the  most 
common  being  the  muscular  nerves.  The  pain 
elicited^  by  pressure  on  the  muscles  or  by  move- 
ments is  usually,  but  erroneously,  regarded  as 
situated  in  the  diseased  viscus.  The  tonus  and 
condition  of  the  muscles  of  the  abdominal  pari- 
etes  are  influenced  by  the  condition  of  the 
viscera  through  the  interconnection  of  their 
nerve    systems    in   the    spinal    cord. 

The    following    are    the    segments    with    which 
w 


338  SURGICAL    APPLIED    ANATOMY   [Part  IV 

each  viscus  is  connected  (Head)  : — Stomach,  6,  7, 
8,  9  D. ;  intestine,  9,  10,  11,   12  D.  ;  rectum,  2,  3, 

4  S.  ;  liver  and  gall  bladder,  7,  8,  9,  10  D. ;  kidney 
and  ureter,  10,  11,  12  D.,  1  L. ;  prostate,  10,  11  D., 

5  L.,  1,  2,  3  S.  ;  epididymis,  11,  12  D.,  1  L. ;  testis 
and  ovary,  10  D. ;  appendages  of  uterus,  11,  12  D., 
1  L.  ;  uterus,  10,  11,  12  D.,  1  L.,  3,  4  S. 

This  nerve  relationship  is  illustrated  in  dis- 
ease in  many  ways.  Thus,  in  acute  peritonitis 
and  in  laceration  of  certain  of  the  viscera  the 
abdominal  muscles  become  rigidly  contracted,  so 
as  to  insure  as  complete  rest  as  possible  to  the 
injured  parts.  In  acute  peritonitis  the  belly  is 
very  hard,  the  respirations  are  purely  thoracic, 
and  so  entirely  do  the  cutaneous  portions  of 
these  nerves  enter  into  the  situation,  that  the 
patient  is  often  unable  to  tolerate  even  the  most 
trifling  pressure  upon  his  abdomen. 

Congenital  deformities  of  the  abdomen.— 
At  the  end  of  the  second  month  of  development, 
part  of  the  intestine  projects  through  the  widely 
open  umbilicus  within  the  cord  when  it  is  only 
covered  by  the  transparent  covering  membrane  of 
that  structure.  In  the  third  month  the  intestines 
retreat  within  the  abdomen,  the  cavity  within  the 
cord  becoming  obliterated  and  the  umbilicus 
closed.  The  process  of  retraction  of  the  intestine 
may  fail  or  even  an  opposite  process  may  occur — 
other  contents  being  added  to  those  normally 
found  within  the  cord.  Thus  result  the  various 
forms  of  congenital  exomphalos,  which  may  vary 
in  severity  from  a  small  hernia  to  a  protrusion 
of  the  whole  of  the  more  movable  viscera.  One 
of  the  most  remarkable  deformities  is  that  known 
as  extroversion  of  the  bladder.  Here,  not  only  is 
a  part  of  the  belly  wall  absent,  but  also  a  part  of 
the  genito-urinary  apparatus.  In  complete  cases 
there  is  an  absence  of  the  umbilicus  and  of  the 
anterior  abdominal  wall  below  it.  There  is  no 
symphysis  pubis,  an  absence  of  the  anterior  wall 
of  the  bladder,  of  the  principal  part  of  the  penis, 
and  the  whole  of  the  roof  of  the   urethra.     The 


Chap.  XVI]  TEJE    ABDOMEN  339 

scrotum,  also,   as  may  be  expected  from  a  refer- 
ence to  the  development  of  that  part,  is  bifid. 

Hernia.— 1.  Inguinal  hernia.  In  this  form 
of  rupture  the  herniated  bowel  occupies  the  in- 
guinal canal  for  the  whole  or  part  of  its  entire 
length.  This  canal  runs  obliquely  from  the  in- 
ternal to  the  external  abdominal  ring,  and  is 
about  lh  inch  in  length.  It  represents  the  track 
followed  by  the  testis  in  its  descent.  It  is,  in 
a  sense,  apassage^  right  through  the  abdominal 
wall,  and  is  occupied  by  the  spermatic  cord.  It 
is  not  a  free  canal,  however,  in  the  same  sense  as 
one  would  speak  of  an  open  tube,  but  is  rather  a 
potential  one,  a  tract  of  tissue  so  arranged  as  to 
permit  of  a  body  being  thrust  along  it.  It  is  a 
breach  in  the  abdominal  wall,  not  a  doorway ; 
a  breach  that  is  forcibly  opened  up  and  widened 
in  the  acquired  forms  of  hernia.  When  a  hernia 
occupies  the  inguinal  canal  it  is  covered  in 
front  by  the  integuments,  the  external  oblique 
aponeurosis,  and  the  lower  fibres  of  the  inter- 
nal, oblique  and  transversalis  muscles.  It  rests 
behind  upon  the  transversalis  fascia,  the  con- 
joined tendon,  and  the  triangular  fascia ;  over 
it  arch  the  transverse  and  internal  oblique 
muscles,  while  below  it  is  the  angle  formed  by 
the  union  of  Poupart's  ligament  with  the  trans- 
versalis fascia.  The  herniated  bowel  is  con- 
tained within  a  "  sac,"  which  is  always  formed 
of  _  peritoneum.  In  congenital  hernia  the  sac 
exists  already  formed  as  an  abnormally  patent 
"  processus  vaginalis."  In  acquired  hernise  the 
sac  consists  of  that  part  of  the  parietal  peri- 
toneum which  the  gut  pushes  before  it  in  its 
descent. 

The  external  abdominal  ring,  half  an  inch  ex- 
ternal to  and  above  the  pubic  spine,  is  readily 
felt  by  invaginating  the  scrotum  with  the  point 
of  the  finger,  and  then  passing  the  digit  up  in 
front  of  the  cord.  If  the  nail  be  kept  against  the 
cord  the  pulp  of  the  finger  can  readily  recognise 
the  triangular  slit-like  opening.     Under  ordinary 


340 


SURGICAL    APPLIED    ANATOMY  [Part  IV 


circumstances  in  adults  it  will  just  admit  the 
tip  of  the  little  finger.*  The  internal  ring  is 
situate  about  \  an  inch  above  Poupart's  liga- 
ment, midway  between  the  symphysis  pubis  and 
anterior  superior  iliac  spine.  This  is  the 
femoral  point;  it  lies  directly  over  the  femoral 
artery  as  that  vessel  escapes  from  the  abdomen 
beneath  Poupart's  ligament  (Fig.  57). 


UnBiLlCUS 

4->-KLunBAB  Vert. 

COfinO"  Iliac  Art 


Ext.  Iliac  Art. 
Rectus  Abdominis 

DEEP  ElPiCASTRiC  Art. 
/lESSELBACtt'S  TBIA/1CLE 

Course  of Vas     , 
Ext.Aboomiial  Rimc 
5y/iPHysis 
Pubic  5pime 
QlMBECflATS  Lica^e^t 
_  From  rhe  FemOBAl  Ri/iC 


Course  o/  vas 
#nd  Cord 


Fig.  57. — Surface  markings  for  the  inguinal  and  femoral  canals. 
a.s.s.,  Anterior  superior  spine  of  ilium. 

There  are  two  principal  forms  of  inguinal 
hernia,  which  can  be  best  understood  by  a  view 
of  the  anterior  abdominal  parietes  from  within. 
From  such  an  aspect  it  will  be  seen  that  the 
peritoneum  is  marked  by  three  linear  ridges  that 
run,  roughly  speaking,  from  the  umbilicus  to  the 

In  cases  of  congenital  or  acquired  absence  of  the  cord  the  external 
ring  maybe  almost,  obliterated.  Paulet  quotes  from  Malgaigne  the  case  of 
an  old  man  wliu.se  testicle  had  been  removed  iii  infancy,  and  in  whom  the 
external  ring  was  so  small  as  to  be  scarcely  recognisable. 


Chap.  XVI]  THE    ABDOMEN  34] 

pelvic  brim.  One  of  these  ridges  follows  the 
middle  line  from  the  navel  to  the  symphysis  and 
represents  the  urachus;  a  second,  that  may  be 
indicated  by  a  line  drawn  from  the  femoral 
point  to  the  navel,  represents  the  deep  epigastric 
artery;  while  between  these  two,  and  much 
nearer  to  the  epigastric  vessel  than  to  the  middle 
line,  is  the  line  formed  by  the  obliterated  hypo- 
gastric artery.  By  means  of  these  ridges  the 
peritoneum  is  made  to  present  three  fossse,  an 
external  to  the  outer  side  of  the  epigastric  artery, 
an  internal  between  the  urachus  and  the  hypo- 
gastric artery,  and  a  middle  between  the  track 
of  the  latter  vessel  and  the  epigastric  trunk. 
The  internal  ring  (so  called)  is  just  to  the  outer 
side  of  the  epigastric  artery,  and  the  site  of 
the  summit  of  the  inguinal  canal  is  indicated  by 
a  depression  in  the  peritoneum  (Fig.  57).  When 
a  hernia  follows  the  inguinal  canal  throughout 
its  entire  length,  it  is  called  oblique,  indirect,  or 
external;  "  oblique  "  or  "  indirect ,;  from  its 
taking  the  oblique  direction  of  the  canal,  "  ex- 
ternal ;;  from  the  position  of  its  neck  with  refer- 
ence to  the  epigastric  vessel.  The  coverings  of 
such  a  hernia  would  be  the  same  as  those  of  the 
cord,  viz.,  the  skin,  the  superficial,  inter- 
columnar,  cremasteric  and  infundibuliform  layers 
of  fascia,  the  subserous  tissue,  and  the  peri- 
toneum. When  the  hernia  escapes  to  the  inner 
side  of  the  deep  epigastric  artery,  through  the 
space  known  as  Hesselbach's  triangle,  it  is  called 
a  direct  or  internal  hernia,  for  reasons  that  will 
be  obvious.  There  may  be  two  forms  of  direct 
hernia.  In  one  form  the  gut  escapes  through  the 
middle  fossa  above  described,  in  the  other 
through  the  inner  fossa  between  the  hypogastric 
artery  and  the  outer  edge  of  the  rectus  muscle. 
The  middle  fossa  is  nearly  opposite  to  the  sum- 
mit of  the  external  ring.  A  hernia  escaping 
through  that  fossa  would  enter  the  inguinal  canal 
some  little  way  below  the  point  of  entrance  of  an 
oblique  hernia,  and  would  have  the  same  coverings 


342  SURGICAL   APPLIED    ANATOMY  [Part  IV 

as  that  hernia,  with  the  exception  of  the  infundi- 
buliform  fascia.  The  first  covering,  indeed,  that 
it  would  receive  from  the  canal  structures  would 
be  the  cremasteric  fascia.  The  inner  fossa  cor- 
responds, so  far  as  the  inguinal  canal  is  con- 
cerned, with  the  external  ring.  A  hernia  escap- 
ing through  this  fossa  would  be  resisted  by  the 
conjoined  tendon  and  the  triangular  fascia. 
These  structures  are  either  stretched  over  the 
hernia  so  as  to  form  one  of  its  coverings,  or  the 
conjoined  tendon  is  perforated  by  the  hernia,  or 
lastly  the  gut  deviates  a  little  in  an  outward 
direction  so  as  to  avoid  the  tendon  and  appear  at 
its  outer  side  (Velpeau).  In  any  case  the  hernia 
is  forced  almost  directly  into  the  external  abdo- 
minal ring.  The  coverings  of  such  hernise  are 
the  skin  and  superficial  fascia,  the  intercolumnar 
fascia,  the  triangular  fascia  and  conjoined  tendon 
(with  the  exceptions  above  mentioned),  the  trans- 
versalis  fascia,  subserous  tissue,  and  peritoneum. 

An  examination  of  the  abdominal  wall,  apart 
from  clinical  experience,  would  lead  one  to  sus- 
pect that  the  direct  hernia  would  be  more  com- 
mon than  the  indirect,  since  the  parietes  are  cer- 
tainly less  resisting  opposite  Hesselbach's  triangle 
than  they  are  in  the  parts  immediately  external 
to  the  epigastric  artery.  Indeed,  just  to  the  outer 
side  of  the  conjoined  tendon  the  belly  wall  is 
remarkably  thin.  These  conditions,  however,  seem 
to  offer  less  facilities  for  the  escape  of  a  hernia 
than  does  the  inguinal  canal  itself.  The  funnel- 
shaped  depression  in  the  peritoneum  at  the  sum- 
mit of  that  canal  seems  to  offer  particular  induce- 
ment for  rupture,  and  there  are,  besides,  certain 
congenital  defects  in  the  vaginal  process  of  the 
peritoneum  that  render  hernia  almost  unavoid- 
able along  the  inguinal  canal. 

Direct  versus  indirect  inguinal  hernia. — 
The  indirect  hernia,  as  just  hinted,  may  be  con- 
genital, the  direct  is  never  congenital.  In  the 
congenital  oblique  hernia  the  outline  of  the  in- 
guinal   canal    and   the    relations    of    the    various 


Chap.  XVI]  THE    ABDOMEN  343 

parts  concerned  are  but  little  disturbed,  and  the 
differences  between  this  form  of  rupture  and  the 
direct  variety  are  conspicuous.  The  acquired 
oblique  hernia,  however,  does  not  present  such  a 
contrast  to  the  direct  form  as  might  be  expected. 
In  the  first-named  rupture,  from  constant  drag- 
ging upon  the  parts,  the  internal  ring  becomes 
more  or  less  approximated  to  the  external  ring, 
and  the  length  of  the  canal,  and  consequently  the 
obliquity  of  the  hernia,  are  considerably  reduced. 
Thus  the  axes  of  the  two  forms  of  rupture  do  not 
present  such  differences  as  to  make  their  nature  at 
once  obvious.  The  direct  hernia,  however,  on  re- 
duction, will  pass  directly  back  into  the  belly, 
while  the  indirect  will,  even  in  old  cases,  take  a 
slight  but  appreciable  direction  outwards.  After 
the  reduction  of  the  direct  hernia,  the  edge  of  the 
rectus  muscle  may  be  readily  felt  to  the  inner  side 
of  the  aperture,  the  protrusion  being,  indeed,  at 
the  semilunar  line.  The  direct  hernia  is  usually 
small  and  globular,  while  the  oblique  rupture  may 
attain  large  size,  and  tends  to  assume  a  pyriform 
outline. 

Forms  of  oblique  hernia,  depending*  upon 
congenital  defects  in  the  "  vaginal  process.*" 
—The  descent  of  the  testis.  It  is  well  known  that 
the  testis  in  the  foetus  descends  from  the  region 
of  the  kidney  into  the  scrotum  by  a  way  through 
the  abdominal  wall  that  is  afterwards  known  as 
the  inguinal  canal  (see  p.  339). 

Its  descent  is  preceded  by  the  passage  into  the 
scrotum  of  a  process  of  the  peritoneum,  the 
vaginal  process.  The  testicle  usually  enters  the 
internal  ring  about  the  seventh  month  of  fcetal 
life,  and  by  the  eighth  month  is  in  the  scrotum. 
The  testis  is  guided  to  its  final  resting  place  by 
the  gubernaculum,  a  band  of  muscular  fibres. 
This>  band  is  attached  below  to  the  anterior  ab- 
dominal parietes,  to  the  pubes  near  the  root  of 
the  penis,  to  the  bottom  of  the  scrotum,  and  to 
the  tuber  ischii  and  sphincter  ani  (Lockwood). 
The  last-named  attachments  serve  to  explain  the 


344  SUKGICAL    APPLIED    ANATOMY   [Part  IV 

occasional  passage  of  the  testis  beyond  the  scrotum 
into  the  perineum  (testis  in  perineo).  In  one 
example  of  this  condition  I  found  it  necessary 
to  divide  a  band  passing  from  the  tuber  ischii 
to  the  testis  before  I  could  place  the  gland  in  the 
scrotum. 

Following  the  gubernaculum  upwards,  it  is 
attached,  first  of  all,  to  the  vaginal  process,  which, 
therefore,  descends  before  the  testis,  then  to  the 
gland  and  epididymis,  and,  lastly,  to  the  peri- 
toneum about  the  bowel  (caecum,  ileum,  or  mesen- 
tery on  the  right  side,  and  sigmoid  flexure  on  the 
left  side). 

The  vaginal  process  is  often  found  open  at 
birth;  one  may  infer  from  the  observations  of 
Zuckerkandl  and  of  Sachs  that,  even  in  children 
three  or  four  months  old,  the  communication  re- 
mains open  in  30  to  40  per  cent,  of  cases.  The 
part  of  the  processus  vaginalis  which  surrounds 
the  testicle  becomes  the  tunica  vaginalis,  while  the 
elongated  tubular  part  between  it  and  the  internal 
abdominal  ring  is  known  as  the  processus  funicu- 
laris.  The  manner  in  which  the  processus  vaginalis 
is  cut  off  is  as  follows.  It  becomes  obliterated 
in  two  places,  at  the  internal  ring  and  at  a  spot 
just  above  the  epididymis,  the  obliteration  usually 
beginning  at  the  higher  point  first.  Supposing 
obliteration  to  have  taken  place  at  these  two 
points,  the  vaginal  process  between  them  will  be 
represented  by  an  isolated  tube.  This  soon 
shrinks,  closes,  and  dwindles  to  an  insignificant 
fibrous  cord.  It  may,  however,  remain  patent  in 
part,  and  if  fluid  accumulates  in  this  patent 
portion,  an  "  encysted  hydrocele  of  the  cord  " 
is  produced.  As  regards  the  mode  of  closure, 
three  contingencies  may  happen,  each  giving  rise 
to  a  particular  form  of  hernia:  (1)  the  "pro- 
cess ;;  may  not  close  at  all;  (2)  it  may  close  at  the 
upper  point  only;  and  (3)  it  may  close  at  the 
lower  point  only. 

(1)  When  the  vaginal  process  is  entirely  open, 
gut  can  readily  descend  at  once  into  the  scrotum. 


Chap.  XVI]  THE    ABDOMEN  345 

Such  a  condition  is  called  a  congenital  hernia. 
Here  the  intestine  is  found  to  occupy  a  large  sac 
of  the  peritoneum,  the  open  orifice  of  which  is 
placed  at  the  internal  inguinal  ring.  The  term 
"  congenital ;;  is  misleading,  as  the  hernia  is 
very  rarely  present  at  birth,  although  it  is  com- 
mon in  early  life. 

(2)  When  the  process  is  closed  only  at  the  in- 
ternal ring  the  unduly  large  tunica  vaginalis 
is  found  to  extend  up  to  that  orifice.  If  a  hernia 
forms  itf  may  invaginate  the  processus  vaginalis. 
This  is  known  as  an  infantile  or  encysted 
hernia.  In  such  a  case  the  tunica  vaginalis  lies 
in  front  of  the  sac,  and  therefore  three  layers  of 
peritoneum  would  have  to  be  cut  through  before 
the  gut  could  be  reached.  The  term  "  infantile  ;; 
was  given  to  this  rupture  because  the  first  cases 
reported  were  met  with  in  infants ;  the  term 
"encysted,"'  because  the  hernial  sac  was  con- 
sidered to  be  enclosed  by  the  sac  of  the  tunica 
vaginalis. 

(3)  The  funicular  process  may  remain  open 
from  the  internal  abdominal  ring  to  the  top  of 
the  testicle  and  there  end,  the  normal  tunica 
vaginalis  being  beyond.  Hernia  into  this  process 
is  called  a  hernia  into  the  funicular  process. 

In  the  first  of  these  forms  the  testicle  is  quite 
enveloped  in  the  hernia.  In  the  second  and  third 
forms,  as  well  as  in  the  acquired  form,  it  is  to 
be  felt  quite  distinct  from  the  rupture,  being 
actually  behind  and  below  it.  Congenital  hernia 
frequently  occurs  in  cases  of  imperfect  descent  of 
the^  testicle ;  this  can  be  readily  understood  when 
it  is  remembered  that  the  processus  vaginalis  is 
completely  formed  before  the  testicle  passes  into 
the  inguinal  canal.  In  such  cases  the  processus 
remains  open.  In  these  instances  the  vaginal  pro- 
cess may  occupy  the  would-be  canal,  and  along 
this  process  a  hernia  may  descend.  It  is  well 
known  that  the  testicle  may  make  its  first  appear- 
ance in  the  scrotum  months  and  even  years  after 
birth. 


346  SURGICAL   APPLIED    ANATOMY  [Part  IV 

There  is  another  possible  congenital  defect  that 
may  predispose  to  hernia,  viz.  an  abnormally  long 
mesentery.  If,  in  the  dead  subject,  the  inguinal 
canal  be  opened  up,  and  an  attempt  made  to  draw 
a  piece  of  gut  down  from  the  abdomen  into  the 
scrotum,  it  will  be  found  that  this  cannot  be  done, 
owing  to  the  shortness  of  the  mesentery.  In  any 
case  of  scrotal  hernia,  therefore,  the  mesentery 
must  become  lengthened,  and  it  is  a  question 
whether  or  not  an  abnormally  long  mesentery  may 
exist  as  a  congenital  defect,  and  so  predispose  tjie 
patient  to  rupture.  More  information  is  required 
upon  the  subject. 

The  inguinal  canal  in  the  female  is  much 
smaller  and  narrower,  although  a  trifle  longer, 
than  it  is  in  the  male.  It  is  occupied  by  the 
round  ligament,  and  offers  such  slight  induce- 
ment to  the  formation  of  a  rupture,  that  acquired 
inguinal  hernia  is  as  rare  among  females  as  it  is 
common  among  men.  In  the  female  foetus  a  pro- 
cess of  peritoneum  descends  for  a  little  way  along 
the  round  ligament.  It  corresponds  to  the  pro- 
cessus vaginalis  of  males,  and  is  known  as  the 
canal  of  Nuck.  If  this  process  remains  patent, 
as  it  not  unfrequently  does,  it  may  lead  to  a  rup- 
ture that  corresponds  to  the  congenital  hernia  of 
males.  Indeed,  in  quite  early  life  the  inguinal 
rupture  is  about  the  only  form  met  with  in 
female  children,  if  exception  be  made  of  umbilical 
hernia.  Not  uncommonly  the  ovary  is  found  as 
one  of  the  contents  of  the  hernial  sac — for  in  the 
newly-born  child  the  ovarv  lies  above  the  level 
of  the  pelvic  brim  and  relatively  near  the  internal 
abdominal  ring.  In  all  such  instances  of  early  in- 
guinal hernia  the  gut  has  travelled  down  a  patent 
canal  of  Nuck. 

It  only  remains  to  be  said,  that  in  endeavour- 
ing to  reduce  an  inguinal  hernia  by  taxis  the 
thi^h  should  be  flexed  and  adducted,  for  in  this 
position  the  abdominal  parietes  that  bound  the 
inguinal  canal  are  the  most  relaxed.  This  posi- 
tion   of    the    thigh    affects    the    inguinal    region 


Chap.  XVI]  THE   ABDOMEN  347 

mainly  through  the  attachments  of  the  fascia  lata 
to  Poupart's  ligament. 

In  Herniotomy  an  incision  is  made  along  the 
middle  of  the  tumour  and  in  its  long  axis,  being 
so  arranged  that  its  centre  shall  correspond  to  the 
external  ring.  The  superficial  external  pudic 
artery  is  usually  divided  in  the  operation.  It  is 
impossible  to  distinguish  the  various  layers  of 
tissue  that  cover  the  hernia,  the  only  one,  as  a 
rule,  that  is  recognisable  being  the  layer  from 
the  cremaster.  In  dividing  the  constriction  it  is 
usually  recommended  to  cut  upwards  in  all  forms 
of  inguinal  hernia.  The  only  vessel  in  risk  of 
being  damaged  is  the  deep  epigastric.  In  the 
oblique  form  of  rupture  an  incision  directly  up- 
wards would  quite  avoid  this  artery;  but  in  a 
direct  hernia,  where  there  is  reason  to  suppose 
that  the  vessel  is  in  close  connection  with  the  neck 
of  the  sac,  it  is  well  that  the  incision  be  directed 
a  little  inwards  as  well  as  upwards.  It  should 
be  remembered  that  the  incision  required  to  re- 
lieve a  constriction  is,  if  properly  applied,  of  the 
most  insignificant  character. 

2.  Femoral  hernia.— In  this  form  of  rupture 
the  gut  leaves  the  abdomen  through  the  femoral 
ring  and  passes  down  into  the  thigh  along  the 
crural  canal  (Fig.  57).  The  name  "  crural  canal  " 
is  given  to  the  narrow  interval  between  the 
femoral  vein  and  the  inner  wall  of  the  femoral 
sheath.  Like  the  inguinal  canal,  it  is  a  potential 
rather  than  an  actual  canal,  and  exists  only  when 
the  sheath  has  been  separated  from  the  vein  by 
dissection  or  by  a  hernial  protrusion  of  some  kind. 
The  canal  is  funnel-shaped,  about  ^  an  inch  in 
length,  and  ends  opposite  the  saphenous  opening. 
A  point  taken  on  Poupart's  ligament  midway  be- 
tween the  pubic  spine  and  femoral  point  lies 
directly  over  the  femoral  ring ;  the  centre  of  the 
saphenous  opening  is  situated  f  of  an  inch  below 
this  point  (Fig.  57).  Femoral  hernise  are  always 
acquired,  and  possess  a  sac,  made  by  themselves 
out  of  the  parietal  peritoneum  covering  the  crural 


348  SUKGICAL    APPLIED    ANATOMY  [Part  IV 

ring  and  its  vicinity.  The  canal  is  larger  in 
women  than  in  men,  and  thus  it  happens  that 
this  species  of  rupture  is  much  more  common  in 
the  former  sex.  The  tendency  to  this  hernia  in 
women  appears  also  to  be  increased  by  the  weak- 
ening effects  of  pregnancy  upon  the  abdominal 
walls.  As  the  gut  descends  it  pushes  in  front  of 
it  its  sac  of  peritoneum  and  the  septum  crurale 
(the  name  given  to  the  subserous  tissue  that  covers 
in  the  femoral  ring)  and  enters  the  crural  sheath. 
The  adhesions  of  the  sheath  limit  its  downward 
progress  when  it  has  travelled  about  £  an  inch, 
and  it  therefore  passes  forwards  through  the 
saphenous  opening,  pushing  before  it  the  cribri- 
form fascia.  It  then  receives  a  covering  from  the 
superficial  fascia  and  the  skin.  Owing  to  the 
rigidity  of  the  structures  about  the  femoral  ring, 
the  neck  of  the  sac  must  always  be  small.  For 
similar  reasons  its  dimensions  while  in  the  femoral 
canal  must  of  necessity  be  insignificant,  but  when 
once  it  has  escaped  through  the  saphenous  open- 
ing the  loose  subcutaneous  fasciae  of  the  groin 
afford  it  ample  opportunity  for  increase.  When 
the  hernia  has  passed  through  the  saphenous  open- 
ing it  tends  to  mount  upwards  over  Poupart's 
ligament,  in  the  direction  of  the  anterior  superior 
iliac  spine.  Even  when  it  overlaps  the  ligament 
considerably  it  can  hardly  be  mistaken  for  an 
inguinal  hernia,  since  it  must  always  lie  to  the 
outer  side  of  the  pubic  spine.  The  upward  ten- 
dency of  a  femoral  hernia  has  been  variously 
explained.  It  has  been  ascribed  to  a  supposed 
curve  in  the  crural  canal,  the  concavity  of  which 
is  forwards.  Scarpa  believed  it  to  receive  its 
direction  from  the  frequent  flexion  of  the  thigh. 
Probably  one  of  the  most  important  factors  in 
the  matter  is  the  unyielding  character  of  the 
lower  edge  of  the  saphenous  opening.  If  an  elas- 
tic capsule  be  dilated  within  the  femoral  canal 
it  will  be  found  to  turn  upwards  and  inwards 
oyer  Poupart's  ligament;  the  direction  of  expan- 
sion is  determined  by  the  circumstances  just  men- 


Chap.  XVI]  THE    ABDOMEN  349 

tioned  and  by  the  yielding  character  of  the  an- 
terior wall  of  the  femoral  sheath.  The  hernial 
sac  is  superficial  to  Scarpa's  fascia. 

Relations.- — When  a  hernia  occupies  the  crural 
canal  there  are  in  front  of  it  the  skin  and  super- 
ficial fasciae,  the  iliac  part  of  the  fascia  lata,  the 
cribriform  fascia,  and  the  anterior  wall  of  the 
crural  sheath.  Behind  are  the  posterior  wall  of 
the  crural  sheath  and  pubic  portion  of  the  fascia 
lata,  the  pectineus  muscle,  and  the  bone.  The 
boundaries  of  the  femoral  ring  are,  in  front,  Pou- 
part;s  ligament  and  the  deep  crural  arch;  behind, 
the  bone  covered  by  the  fascia  lata  and  the  pec- 
tineus; on  the  inner  side,  the  conjoined  tendon, 
Gimbernat's  ligament,  and  the  inner  part  of 
the  deep  crural  arch;  on  the  outer  side,  the 
femoral  vein  in  its  sheath  (Fig.  57).  The  sper- 
matic cord  lies  (in  the  male)  just  above  the  an- 
terior border  of  the  ring,  and  the  epigastric  artery 
skirts  its  upper  and  outer  part.  The  little  pubic 
branch  of  this  artery  passes  round  the  ring  to 
ramify  over  Gimbernat's  ligament.  In  two  cases 
out  of  seven  the  obturator  artery  arises  from  the 
epigastric.  In  10  per  cent,  of  cases  the  abnormal 
obturator  passes  on  the  inner  side  of  the  femoral 
ring  and  is  in  danger  of  being  wounded  in  opera- 
tions for  strangulation  ;  in  other  cases  the  artery 
descends  to  the  outer  side  of  the  ring  or  may  cross 
it  (R.  Quain).  In  one  instance  where  the  vessel 
was  placed  internally  to  the  femoral  ring  the  pul- 
sations of  the  abnormal  artery  were  felt  before  the 
parts  were  divided.  In  addition  to  the  vessels 
about  the  ring  there  is  also  a  pubic  vein,  which, 
ascending  from  the  obturator  vein  in  the  thyroid 
foramen,  enters  the  external  iliac  vein.  Its  rela- 
tion to  the  crural  ring  varies  in  the  same  way  as 
the  abnormal  artery  last  named. 

The  size  of  the  femoral  canal  and  the  degree 
of  tension  of  its  orifices  vary  greatly  with  the 
position  of  the  limb.  If  the  thigh  be  extended, 
abducted,  and  rotated  outwards,  these  parts  are 
made  very  tense,  while  they  are  the  most  lax  when 


350  SURGICAL    APPLIED    ANATOMY   [Part  IV 

the  limb  is  flexed,  adducted,  and  rotated  inwards. 
It  is  consequently  in  the  latter  position  that  the 
thigh  should  be  placed  when  taxis  is  being  at- 
tempted. In  herniotomy  the  incision  is  made 
along  the  inner  side  of  the  tumour,  and  is  so 
arranged  that  its  centre  corresponds  to  about 
the  upper  part  of  the  saphenous  opening.  The 
constriction  is  usually  at  the  neck  of  ^ the  sac,  and 
caused  by  Gimbernat's  ligament.  It  is  divided  by 
an  incision  directed  upwards  and  inwards. 

3.  Obturator  hernia. — In  this  form  the  gut, 
pushing  before  it  the  peritoneum,  the  subperi- 
toneal fat,  and  the  pelvic  fascia,  escapes  through 
the  obturator  canal.  The  direction  of  this  canal 
is,  from  behind,  downwards,  forwards,  and  in- 
wards. The  inguinal  is  separated  from  the 
femoral  canal  by  the  inner  part  of  Poupart's 
ligament;  the  femoral  is  separated  from  the  ob- 
turator bv  the  horizontal  ramus  of  the  pubis. 

Beyond  the  canal  the  hernia  may  pass  between 
the  obturator  membrane  and  the  obturator  exter- 
nus  muscle  and  remain  deeply  placed,  or  it  may 
make  its  way  through  the  muscle  or  emerge  above 
it  and  be  then  covered  by  the  pectineus  and  adduc- 
tor brevis.  The  obturator  artery  is,  as  a  rule, 
at  the  outer  and  posterior  part  of  the  sac.  It  is 
very  rarely  in  front  of  it.  The  obturator  nerve 
is  generally  found  to  the  outer  side  of  the  sac, 
less  commonly  it  is  in  front  of  it.  The  proximity 
of  the  nerve  renders  it  very  liable  to  be  pressed 
upon,  and  pain  along  the  nerve  is  often  a  marked 
feature  of  the  rupture.  The  hernia  presents  be- 
neath the  pectineus  muscle,  to  the  inner  side  of 
the  capsule  of  the  hip,  behind  and  to  the  inner 
side  of  the  femoral  vessels,  and  to  the  outer  side 
of  the  adductor  longus  tendon.  Pain  on  moving 
the  hip  is  generally  a  conspicuous  symptom.  The 
obturator  externus  may  be  made  tense  bv  rotation 
inwards  of  the  slightly  abducted  thigh.  This 
hernia  is  much  more  common  in  females ;  and  it 
is  worthy  of  note  that  the  orifice  of  the  obturator 
canal  can  be  examined,  to  some  extent,   through 


Chap.  XVI]  THE    ABDOMEN  351 

the  vagina.  Professor  Wood  reports  a  remarkable 
case  where  a  hernial  protrusion  of  a  part  of  the 
adductor  longus  through  a  rent  in  the  fascia  lata 
was  mistaken  for  an  obturator  hernia. 

1.  Rare  forms  of  hernia. — In  perineal  hernia 
the  sac,  covered  by  the  recto-vesical  fascia,  escapes 
through  the  anterior  fibres  of  the  levator  ani 
muscle,  between  the  prostate  and  the  rectum.  In 
the  ischio-rectal  hernia  the  protrusion  takes  place 
into  the  ischio-rectal  fossa.  In  pudendal  hernia 
the  sac  lies  in  the  posterior  inferior  half  of  the 
labium  pudendi,  escaping  between  the  ascending 
ramus  of  the  ischium  and  the  vagina ;  it  has  been 
mistaken  for  a  cyst.  In  sciatic  hernia  the  gut 
escapes  through  the  great  sacro-sciatic  notch  in 
front  of  the  internal  iliac  vessels,  above  or  below 
the  pyriformis,  and  appears  under  the  gluteus 
maximus  muscle.  As  regards  umbilical  hernia, 
nothing  remains  to  be  added  to  what  has  been 
already  said  (p.  328),  save  that  the  sac  from  its 
position  nearly  always  contains  omentum,  and 
may  contain  stomach.  In  lumbar  hernia  the  gut 
escapes  in  front  of  the  quadratus  lumborum 
muscle,  and  appears  on  the  surface  through  the 
triangle  of  Petit  (the  gap  between  the  latissimus 
dorsi  and  external  oblique  muscles),  and  there- 
fore just  above  the  highest  point  of  the  iliac  crest. 
The  sac  must  either  force  before  it  or  (in  cases  of 
injury)  come  through  the  fascia  lumborum  and 
internal  oblique  muscles,  since  these  structures 
form  the  floor  of  the  triangle.  The  hernia  may 
escape  through  the  "  upper  lumbar  triangle  " — 
a  gap  near  the  last  rib  where  the  aponeurosis  of 
the  transversalis  is  covered  only  bv  the  latissimus 
dorsi.  Macready  (Lancet,  Nov.  8th,  1890)  has  col- 
lected twentv-five  examples  of  this  hernia.  Dia- 
vhraqmatic  hernias  may  be  congenital  or  acquired. 
The  former  variety  is  by  far  the  more  common,  and 
is  due  to  simple  arrest  in  the  development  of  the 
diaphragm  and  persistence  of  the  original  connec- 
tion between  the  thorax  and  abdomen  ;  the  position 
of  this  connection  is  marked  by  the  fibrous  interval 


352  SUEGICAL    APPLIED    ANATOMY   [Part  IV 

between  the  muscular  fibres  rising  from  the  last  rib 
and  those  springing  from  the  external  arcuate  liga- 
ment. The  congenital  form  very  rarely  occurs  on 
the  right  side,  the  development  of  the  liver  secur- 
ing the  closure  of  the  pleuro-peritoneal  opening 
on  that  side.  In  the  acquired  form,  which  is 
usually  the  result  of  a  crushing  accident,  the  dia- 
phragm may  be  lacerated  at  any  point,  but  in  the 
majority  of  instances  the  lesion  is  situated  in  the 
left  dome  over  the  stomach.  In  an  adult  subject 
recently  dissected  by  Dr.  N.  Paterson  the  ab- 
dominal contents  of  the  left  hypochondrium  occu- 
pied the  left  pleural  cavity ;  there  was  a  large 
aperture  in  the  left  dome ;  the  condition  had  not 
been  recognised  during  life  and  apparently  had 
given  rise  to  no  marked  symptom.  Of  the  organs, 
the  stomach  is  the  most  frequently  dislodged,  then 
the  transverse  colon,  omentum,  small  gut,  spleen, 
liver,  pancreas,  and  kidneys,  in  the  order  named 
(Leichtenstern).  The  hernia  may  escape  through 
the  foramen  for  the  gullet,  but  never  through  that 
for  the  vena  cava,  nor  through  the  hiatus  aorticus. 
The  parts  commonly  selected  are  the  connective 
tissue  intervals  between  the  sternal  and  costal 
origins  of  the  diaphragm  in  front  and  its  verte- 
bral and  costal  origins  behind.  These  hernise  are 
more  common  in  males. 

Femoral  and  inguinal  diverticula. — Re- 
cently Mr.  It.  W.  Murray  has  called  attention  to 
the  frequency  with  which  diverticula  of  peri- 
toneum are  found  over  the  openings  of  the  femoral 
and  inguinal  canals.  In  200  post-mortem  ex- 
aminations he  found  52  femoral  and  13  inguinal 
diverticula  and  yet  no  hernia.  In  some  cases  the 
inguinal  sacs  may  be  formed  from  the  processus 
vaginalis,  but  all  the  femoral  forms  and  probablv 
the  majority  of  the  inguinal  are  caused  by  yield- 
ing of  the  fibrous  tissue  of  the  parietes  over  the 
femoral  and  internal  abdominal  rings.  In  these 
regions  the  peritoneum  is  so  loosely  bound  to  the 
abdominal  wall  that  it  may  be  evaginated  by  a 
low  degree  of  intra-abdominal  pressure. 


Chap.  XVI]  THE    ABDOMEN  353 

Posterior  abdominal  parietes. — The  lateral 
and  posterior  walls  of  the  abdomen  are  lined  in- 
side with  two  fasciae,  the  transversalis  and  iliac. 
The  transversalis  fascia  lines  the  whole  of  the 
transversalis  muscle,  and  is  much  thicker  below 
than  above.  Above,  it  joins  the  fascia  covering  the 
diaphragm,  while  below  it  is  attached  to  the  iliac 
crest  and  to  the  whole  of  Poupart's  ligament,  save 
at  that  spot  where  it  passes  into  the  thigh  to 
form  the  anterior  layer  of  the  crural  sheath.  The 
iliac  fascia  encloses  the  ilio-psoas  muscle,  the  part 
over  the  psoas  being  the  thinner.  This  part  is 
attached  on  the  inner  side  to  the  sacrum,  and  to 
the  spine  at  the  points  corresponding  to  the  psoas 
origin.  Above,  it  is  attached  to  the  ligamentum 
arcuatum  internum,  and  on  the  outer  side  to  the 
anterior  layer  of  the  lumbar  fascia  along  the 
outer  edge  of  the  psoas.  Below,  the  fascia  en- 
closes the  iliacus,  and  is  attached  to  the  iliac  crest, 
to  the  pelvic  brim,  and  to  Poupart's  ligament, 
save  at  that  part  where  the  membrane  passes  be- 
neath the  ligament  to  form  the  posterior  wall  of 
the  crural  sheath.  It  follows  the  ilio-psoas  muscle 
to  its  insertion,  and  ends  by  blending  with  the 
fascia  lata. 

The  arrangement  of  these  fasciae  greatly  influ- 
ences the  progress  and  direction  of  abscess.  Thus 
an  abscess  placed  beneath  the  transversalis  fascia 
will  point  either  just  above  the  iliac  crest  or  Pou- 
part's ligament,  or  run  down  along  the  spermatic 
cord  and  distend  the  inguinal  canal. 

The  iliac  fascia  encloses  the  ilio-psoas  in  a 
very  distinct  osseo-aponeurotic  space.  Between  the 
fascia  and  the  muscle  (especially  its  iliac  division) 
there  is  a  good  deal  of  loose  connective  tissue, 
and  thus  every  facility  is  offered  for  the  progress 
of  subfascial  abscesses  in  this  region.  The  osseo- 
aponeurotic  space  is  practically  closed  on  all  sides 
within  the  abdomen,  and  is  only  open  below  where 
the  fascia  passes  with  its  muscle  into  the  thigh. 
This  opening  being  at  the  most  dependent  part  of 
the  space,  it  follows  that  the  psoas  or  iliac  abscess 
x 


354  SUKGICAL    APPLIED    ANATOMY      [Part  IV 

very  commonly  points  on  the  upper  part  of  the 
thigh,  just  to  the  outer  side  of  the  femoral  vessels. 
An  abscess  in  the  iliac  fossa,  although  most  likely 
to  reach  the  thigh,  might  mount  up  to  the  superior 
attachments  of  the  fascia,  and  point  at  the  iliac 
crest  or  at  the  outer  part  of  Poupart's  ligament. 
Or  it  may  disregard  the  inner  attachments  of  the 
fascia  and  gravitate  into  the  pelvis.  If  the 
patient  should  occupy  for  long  the  recumbent  pos- 
ture, there  is  no  reason  why  it  should  not  extend 
upwards  along  the  psoas  muscle. 

The  term  iliac  abscess,  however,  is  often  ap- 
plied to  collections  that  are  not  within  the  space 
formed  by  the  iliac  fascia,  but  that  are  situated 
rather  in  the  subperitoneal  connective  tissue. 
This  tissue  is  very  extensive  and  lax  in  the  iliac 
fossa  in  order  to  allow  the  expansion  of  the 
peritoneum  which  necessarily  attends  the  filling 
and  emptying  of  the  caecum,  colon,  bladder, 
uterus,  and  rectum.  Large  collections  of  puru- 
lent matter  may  form  in  it  or  may  spread  into  it 
from  the  pelvis.  Some  distance  above  Poupart;s 
ligament  (1^  to  2  inches)  the  subserous  tissue  be- 
comes dense  and  the  peritoneum  closely  bound 
down.  Hence  such  abscesses  remain  in  the  iliac 
fossa,  bulging  out  the  abdominal  wall  just  above 
Poupart's  ligament,  and  occupying  the  angle 
formed  by  the  union  of  the  iliac  and  transversalis 
fasciae.  In  some  cases  they  are  disposed  to  extend 
into  the  pelvis. 

The  abscess,  when  in  the  subserous  tissue,  is 
brought  in  close  contact  with  certain  of  the  vis- 
cera, especially  with  the  caecum  and  sigmoid 
flexure,  and  into  these  portions  of  the  colon  it 
may  open.  Thus,  I  have  seen  a  case  of  iliac 
abscess  due  to  pelvic  necrosis  that  opened  into  the 
sigmoid  flexure,  and  at  the  same  time  discharged 
through  sinuses  about  the  groin.  In  this  case 
some  pus  passed  by  the  anus,  while  on  the  other 
hand  some  faecal  matter  escaped  by  the  groin. 
Retroperitoneal  abscesses  in  the  pelvis  (pelvic 
cellulitis)  may  mount  up  into  the  iliac  fossae,  may 


Chap.  XVI]  THE    ABDOMEN  355 

appear  as  "  iliac  abscesses,"  and  may  ultimately 
discharge  themselves  by  many  openings  in  the 
lower  parts  of  the  anterior  abdominal  wall. 

It  may  be  well  to  note  that  the  common  and 
external  iliac  vessels,  the  lymphatics,  and  the 
ureters  are  outside  the  iliac  fascia,  and  rest  upon 
its  abdominal  surface,  while  the  anterior  crural 
nerves  and  abdominal  parts  of  the  lumbar  nerves 
are  within  the  osseo-aponeurotic  space.  Thus  the 
intrafascial  abscess  may,  with  little  difficulty, 
reach  the  thigh  by  following  the  iliac  vessels; 
while  the  subfascial  collection  would  pursue  the 
anterior  crural  nerve. 

A  psoas  abscess,  or  abscess  within  the  fascial 
sheath  of  the  psoas  muscle,  is  usually  due  to  spinal 
caries,  although  it  may  appear  independently  of 
that  disease.  If  the  lumbar  spine  be  involved  the 
matter  can  pass  directly  into  the  substance  of  the 
muscle,  which  it  will  more  or  less  entirely  destroy. 
If  the  mischief  be  in  the  dorsal  spine,  the  matter 
gravitates  along  the  front  of  the  column  until 
it  reaches  the  diaphragm,  which  it  pierces  by  an 
inflammatory  process.  It  is  now  brought  into  re- 
lation with  the  heads  of  the  psoas,  and  has  to  pass 
through  a  narrow  strait.  The  pus,  following  the 
muscle,  at  last  reaches  the  thigh,  and  usually 
points,  just  below  the  groin,  to  the  outer  side  of 
the  femoral  vessels.  The  substance  of  the  psoas 
may  be  completely  replaced  by  an  abscess  cavity. 

The  abscess,  however,  often  shows  much  varia- 
tion. It  may  avoid  the  psoas,  or  leave  it  when 
once  it  has  entered  it,  and  make  its  way  into 
the  lumbar  region  to  find  an  exit  in  the  loin.  Or 
it  may  extend  into  the  iliac  fossae  and  open  above 
the  groin,  or  mount  up  over  the  iliac  crest  and 
discharge  in  the  gluteal  region.  It  may  pass 
along  the  inguinal  canal  and  be  mistaken  for  a 
hernia.  It  may  sink  into  the  pelvis,  and  may 
open  into  the  bladder,  or  discharge  itself  through 
the  great  sciatic  foramen,  or  through  a  sinus  in 
the  perineum.  Some  of  the  latter  cases  have  led 
to  much  confusion  in  diagnosis,  since  there  would 


356  *  SURGICAL    APPLIED    ANATOMY      [Part  IV 

appear   to  be  little  connection   between   caries  of 
the  spine  and  a  perineal  abscess. 

Lumbar  region. — The  muscles  that  form  the 
lateral  and  posterior  walls  of  the  abdomen,  and 
that  fill  in  the  interval  between  the  iliac  crest  and 
the  lowest  rib,  are  the  external  oblique  and  latis- 
simus  dorsi,  the  internal  oblique,  the  transver- 
salis  muscle  and  fascia  lumborum,  the  erector 
spinse  and  quadratus  lumborum.  The  distance 
from  the  iliac  crest  to  the  tip  of  the  nearest  rib 
(usually  the  eleventh)  varies  from  3  to  7  cm,  the 
average  being  4'8  cm.,  a  little  less  than  2  inches 
(Addison). 

The  external  oblique  and  latissimus  dorsi  mus- 
cles are  separated  by  a  small  triangular  interval 
below  (the  triangle  of  Petit),  but  above  they  over-, 
lap.  The  interval  is  best  marked  in  women.  The 
outer  border  of  the  erector  spinse  affords  a  useful 
landmark  in  the  lumbar  region.  At  the  crest  of 
the  ilium  the  outer  border  of  the  quadratus  lum- 
borum extends  an  inch  beyond  the  erector  spinse, 
but  at  the  twelfth  rib  it  lies  an  inch  internally  to 
that  muscle  (Fig.  68).  The  triangle  of  Petit  is 
l\  to  2  inches  beyond  the  erector  spinas,  or  just 
behind  the  mid-point  of  the  iliac  crest.  The  sub- 
cutaneous tissue  in  the  lumbar  region  is  very 
extensive,  and  is  a  favourite  locality  for  chronic 
abscess.  The  looseness  and  extent  of  the  tissue 
also  permit  of  large  extravasations  of  blood.  It 
is  in  the  muscles  and  fascia  along  the  spine  in 
this  region  that  the  rheumatic  affection  known  as 
lumbago  has  its  seat. 

Between  the  last  rib  and  the  iliac  crest  is 
stretched  the  dense  fascia  lumborum,  the  posterior 
aponeurosis  of  the  transversalis  muscle.  It  is 
pierced  near  the  rib  by  the  last  intercostal  artery 
and  nerve,  and  near  the  ilium  by  the  ilio-hypo- 
gastric  nerve  and  its  accompanying  artery.  It  is 
along  these  structures  that  an  abscess  may  possi- 
bly find  its  way  through  the  fascia  in  certain 
cases.  The  fascia  divides  behind  into  three  layers, 
to   enclose   in   definite   spaces   the   quadratus   and 


Chap.  XVI]  THE    ABDOMEN  357 

erector  spinas  muscles,  the  middle  layer  passing 
between  these  two  muscles  to  the  tips  of  the  trans- 
verse processes.  Within  these  spaces  or  compart- 
ments suppuration  may  be  for  some  time  limited. 
A  lumbar  abscess  commencing  in  some  adjacent 
part,  as  in  the  spine  or  in  the  loose  tissue  around 
the  kidneys,  usually  spreads  backwards  by  pierc- 
ing the  fascia  lumborum  or  the  quadratus  muscle. 
It  then  finds  its  way  through  the  internal  oblique, 
and  appears  on  the  surface  between  the  external 
oblique  and  latissimus  dorsi  muscles,  and  at  the 
outer  border  of  the  erector  spinse. 

Tlie  author's  operation  for  caries  of  the 
lumbar  vertebra?.  —  The  lumbar  vertebrae,  and, 
possibly,  the  last  dorsal,  may  be  reached  by  an  in- 
cision through  the  loin.  A  vertical  cut  is  made 
along  the  outer  edge  of  the  erector  spines  muscle. 
The  fibres  of  that  muscle  having  been  drawn 
aside,  the  middle  layer  of  the  fascia  lumborum 
is  incised,  and  the  quadratus  lumborum  is  ex- 
posed. This  muscle  is  divided  vertically,  and  then 
the  front  of  the  vertebras  may  be  reached  by  in- 
troducing the  finger  under  the  psoas  muscle. 
Through  this  incision  the  author  has  removed  the 
whole  of  the  body  of  the  first  lumbar  vertebra  that 
had  been  separated  as  a  sequestrum.  (Med.-Chir. 
Trans.,  1884.)  The  lumbar  arteries  are  avoided 
by  keeping  close  to  the  transverse  processes  of  the 
vertebras.  Through  this  incision  a  psoas  abscess 
may  be  most  conveniently  opened. 


CHAPTER   XVII 

THE   ABDOMINAL   VISCERA 

The  peritoneum. — Certain  of  the  viscera,  as, 
for  example,  the  stomach,  spleen,  and  small  in- 
testines, are  so  closely  invested  with  peritoneum 
that  theycould  not  be  wounded  without  that  mem- 
brane being  wounded  also.  Inflammatory  affec- 
tions of  such  viscera  are  also  very  apt  to  involve 
the  peritoneum.  Other  organs,  such  as  the  kid- 
ney, descending  colon,  pancreas,  etc.,  are  so  im- 
perfectly covered  with  the  serous  membrane  that 
a  wound  of  those  organs  need  not  involve  it,  nor 
need  it  be  implicated  in  even  extensive  inflamma- 
tory changes.  Large  abscesses  may,  for  instance, 
form  about  the  kidney  and  discharge  themselves 
through  the  skin  without  any  peritonitis  being 
induced.  Spontaneous  perforation  of  the  small 
intestine  must  involve  the  peritoneum,  while,  on 
the  other  hand,  the  duodenum  and  ascending 
colon  may  become  perforated,  and  the  matter 
escape  into  the  subserous  tissue  without  the  serous 
membrane  being  in  any  way  involved.  It  is  note- 
worthy in  connection  with  bacterial  infection  that 
it  is  singularly  easy  to  set  up  inflammation  of 
the  peritoneum  if  the  membrane  be  approached 
from  its  inner  surface,  but  comparatively  difficult 
if  it  be  approached  from  without.  Thus  a  small 
puncture  of  the  membrane  may,  on  the  one  hand, 
lead  to  fatal  peritonitis,  while,  on  the  other,  it 
may  be  extensively  torn  from  its  attachments 
(as  in   ligaturing   the  common   iliac  artery  from 

358 


Chap.  XVII]        ABDOMINAL    VISCERA  359 

the  side)  without  any  peritonitis  following.  Or, 
again,  a  little  pus  escaping  on  the  inner  surface 
of  the  membrane  may  lead  to  inflammation,  while 
the  outer  surface  may  be  bathed  with  pus  for  a 
long  while  (as  in  large  perirenal  abscesses)  with- 
out any  peritonitis  being  produced.  Fluid  is 
rapidly  absorbed  from  the  peritoneal  cavity ; 
carmine  particles  are  found  within  the  thoracic 
duct  seven  minutes  from  their  injection  within 
the  cavity;  absorption  takes  place  most  rapidly 
in  the  subdiaphragmatic  area  (Dunbar  and  Remy). 
Inflammation  of  the  peritoneum  may  lead  to  the 
formation  of  a  great  variety  of  bands  and  ad- 
hesions, beneath  which  pieces  of  intestine  may  be 
caught  and_  strangulated. 

The  peritoneum  will  allow  of  very  consider- 
able stretching  if  only  that  stretching  be  effected 
gradually.^  This  is  frequently  seen  in  cases  of 
gradual  distension  of  the  bowel,  in  the  formation 
of  the  sac  in  hernia,  and  in  the  growth  of  retro- 
peritoneal tumours.  Abrupt  stretching  of  the 
membrane  leads  to  certain  rupture  of  it.  The 
parietal  peritoneum  may  be  ruptured  by  violence 
without  damage  to  any  of  the  viscera. 

The  great  omentum  is,  from  its  position, 
very  apt  to  be  wounded.  In  small  wounds  of  the 
front  of  the  belly  it  very  often  protrudes  and  acts 
as  an  excellent  plug  to  prevent  the  escape  of 
other  and  more  important  structures.  It  is  often 
found  in  hernia,  especially  in  umbilical  hernia, 
where  it  is  almost  constant.  Its  limits  vary,  and 
it  has  an  inclination  to  the  left  side.  This 
depends  upon  the  fact  that  the  omentum  is 
developed  from  the  rnesogaster,  and  accounts  for 
the  fact  that  hernise  containing  omentum  are 
much  more  common  on  the  left  side.  The  omen- 
tum, like  the  other  parts  of  the  peritoneum,  is 
apt  to  inflame,  and  to  contract  adhesions  to  the 
neighbouring  parts.  These  adhesions  are  often 
of  the  greatest  service  in  limiting  inflammatory 
and  hsemorrhagic  extravasations,  by  matting  the 
bowels  together  and  forming  spaces  between  them. 


360  SUKGICAL    APPLIED    ANATOMY     [Part  IV 

In  perforation  of  the  bowels  from  disease,  an 
opportune  adhesion  of  the  omentum  over  the  aper- 
ture may  prevent  escape  of  the  intestinal  con- 
tents. 

Large  masses  of  tissue  may  be  nourished 
through  an  adherent  omentum.  Thus  when  the 
proper  blood  supply  of  an  ovarian  tumour  has 
been  cut  off  by  twisting  of  its  pedicle,  the  growth 
may  be  nourished  through  the  omentum,  if  that 
structure  is  adherent  to  it.  Rutherford  Morri- 
son proposes  to  relieve  congestion  of  the  portal 
circulation  by  setting  up  an  anastomosis  between 
the  omental  vessels  and  the  systemic  circulation. 
When  an  adhesion  between  the  omentum  and 
parietal  peritoneum  is  produced  artificially,  large 
anastomotic  vessels  open  up  and  communicate 
with  the  vascular  network  beneath  the  parietal 
peritoneum,  thus  possibly  relieving  tension  in 
cases  of  obstructed  portal  circulation.  In  cases 
of  obesity  fat  collects  conspicuously  in  the  great 
omentum.  In  hernise  the  omentum  generally  con- 
tracts adhesions  to  the  sac,  and  becomes  irreduc- 
ible, or  it  may  form  a  kind  of  second  sac  about  the 
gut  itself  ("  omental  sac  ,;).  The  end  of  the  omen- 
tum, by  becoming  adherent  to  distant  parts,  as  to 
the  pelvic  viscera,  may  form  itself  into  a  firmly 
attached  band,  beneath  which  the  bowel  may  be 
fatally  strangled.  In  like  manner  the  intestine 
has  been  strangulated  through  slits  and  holes  that 
have  developed  in  the  omentum,  usually  as  a  re- 
sult of  inflammatory  adhesions.  The  functional 
meaning  of  the  great  omentum  is  by  no  means 
definitely  established,  but  it  undoubtedly  increases 
the  absorptive  area  of  the  peritoneum,  and  evi- 
dence is  not  lacking  to  show  that  it  takes  an  active 
part  in  repelling  bacterial  invasions  of  the  peri- 
toneal cavity. 

The  mesentery. — The  parietal  attachment  of 
the  mesentery  is  liable  to  some  variation.  The 
point  at  which  this  attachment  commences  above 
is  practically  constant.  It  corresponds  with  the 
ending  of.  the  duodenum,  is  about  on  a  level  with 


Chap.  XVII]        ABDOMINAL    VISCEEA  361 

the  lower  border  of  the  pancreas,  and  is  just  to 
the  left  of  the  second  lumbar  vertebra.  (See  p.  366.) 
From  this  point  the  insertion  of  the  mesentery 
follows  an  oblique  line  that  runs  downwards 
and  to  the  right,  crossing  the  great  vessels,  and 
then  ending  in  a  somewhat  uncertain  manner  on 
the  right  iliac  fossa  (Fig.  58,  p.  363).  The  parietal 
attachment  of  the  mesentery  measures,  as  a  rule, 
about  6  inches.  From  its  oblique  attachment  it 
follows  that,  when  haemorrhage  takes  place  in  the 
abdomen  on  the  right  side  of  the  mesentery,  the 
blood  first  is  conducted  into  the  right  iliac  fossa ; 
when  on  the  left  side,  into  the  pelvis.  This  may 
explain  the  circumstance  that  collections  of  blood 
are  more  common  in  the  right  than  in  the  left 
iliac  fossa. 

The  length  of  the  mesentery  from  the  spine  to 
the  bowel  varies  in  different  parts  of  the  canal ; 
its  average  length  is  8  inches.  The  longest  part 
is  that  which  goes  to  the  coils  of  intestine  that 
lie  between  a  point  6  feet  from  the  duodenum,  and 
a  point  11  feet  from  the  same  part  of  the  gut 
(Author).*  Such  coils  will,  therefore,  include 
5  feet  of  the  intestine,  and  the  mesentery  here 
may  reach  the  length  of  10  inches.  These  coils 
are  apt  to  hang  in  the  pelvis,  and  may  be  easily 
herniated.  The  length  of  the  mesentery  plays  an 
important  part  in  hernia.  If  the  fresh  body  of 
an  adult  be  opened,  and  the  condition  of  the  vis- 
cera and  peritoneum  be  normal,  it  will  be  found 
that  it  is  impossible  to  drag  a  loop  of  small  in- 
testine through  the  femoral  canal  (artificially  en- 
larged) on  to  the  thigh,  or  down  the  inguinal 
canal  into  the  scrotum.  In  fact,  no  coil  can,  in 
any  part,  be  drawn  out  of  the  abdomen  below  a 
horizontal  line  on  a  level  with  the  spine  of  the 
pubes.  It  is  evident,  therefore,  that  in  femoral 
or  scrotal  hernia  the  mesentery  must  be  elongated 
or  its  attachments  lowered. 

The  mesentery  is  relatively  longest  in  infancy 

See  "  The  Anatomy  of  the  Intestinal  Canal  ami  Peritoneum  in  Man  " 
by  the  Author.     London,  1SS5 


362  SUEGICAL   APPLIED    ANATOMY     [Part  IV 

and  childhood,  and  a  freer  escape  of  the  intestines 
from  the  abdomen  is  allowed  in  subjects  under 
puberty.  The  disposition  of  the  membrane  per- 
mits also  a  freer  downward  excursion  of  the 
bowels  on  the  right  side,  and  this  has  been  offered 
as  an  explanation  of  the  undue  frequency  of  right- 
sided  inguinal  hernise  in  childhood  (Lockwood). 

Mr.  Lockwood  states  that  in  acquired  hernia 
the  mesentery  is  found  to  have  had  its  attachments 
lowered  rather  than  to  have  been  increased  in 
length. 

Certain  holes  are  sometimes  found  in  the 
mesentery,  through  which  intestine  has  been 
strangulated.  Some  of  these  holes,  especially 
those  that  are  slit-like,  are  due  to  injury,  others 
are  due  to  congenital  defect  of  the  mesentery.  I 
have  shown  that  the  latter  holes  are  round,  are  in 
the  mesentery  of  the  lower  ileum,  and  occupy  an 
oval  area,  circumscribed  by  an  anastomotic  arch 
between  the  ileo-colic  branch  of  the  superior 
mesenteric  artery  and  the  last  of  the  intestinal 
arteries.  This  area  is  often  the  seat  of  atrophied 
peritoneum,  and  shows  an  absence  of  fat,  of 
visible  blood-vessels,  and  of  glands.  It  would  be 
easy  for  a  knuckle  of  gut  to  be  forced  through  the 
thinned  membrane,  which  is  sometimes  already 
cribriform. 

Peritoneal  spaces  and  communications. — 
Owing  to  the  arrangement  of  the  peritoneum  the 
cavity  of  the  abdomen  is  divided  into  a  number 
of  potential  spaces  which  are  connected  together 
by  certain  definite  communications  or  routes. 
Alimentary  contents,  pus,  or  blood  escaping 
within  the  peritoneal  cavity  tend  to  collect  in 
certain  of  these  spaces  and  overflow  into  neigh- 
bouring spaces  in  well-defined  directions.  Some 
writers  see  in  this  arrangement  of  the  peritoneum 
a  resemblance  to  the  watersheds  of  a  country,  and 
hence  the  potential  spaces  and  routes  are  some- 
times spoken  of  as  the  "  watersheds  of  the  peri- 
toneum." The  chief  of  these  spaces  are  :  (1)  the 
lesser  sac ;  it  communicates  with  (2)  the  subhepatic 


Chap.  XVItj         ABDOMINAL    VISCERA 


3G3 


space  by  the  foramen  of  Winslow ;  this  space  is 
bounded  above  by  the  under  surface  of  the  liver 
and  below  by  the  duodenum,  hepatic  flexure  of 
colon,  transverse  mesocolon,  right  kidney,  and 
right   costo-phrenic   ligament    (Fig.    58) ;    (3)    the 


Subphrenic  Space 


Call  Bladder 
Subhepatic  5pace 


Pericardium 
-A 

0E"5DT7r'0RIFICE. 


.Stomach 
Spleen 
/ 


Paracolic  C,r 
Ileo-Colic  Jiw 

ft/HT  Sup  I li 


.Spleaiic  Flexure 
"Duode/io  Je  J.  Flexure 


G 

Paracolic  Groove 

Iliac  Colon 
/ 

r> 


Fig.  58. 


-Diagram  showing  the  average  position  of  the  abdominal  viscera 
with  their  surface  markings.     (After  Addison.) 

A,  Stsrno-ensiform  point;  a 'a',  sterno-ensiform  line;  b,  mid-epigastric  point; 
b'b',  mid-epigastric  or  transpyloric  line;  c,  umbilical  point;  c'c',  umbilical 
line;  d,  mid-bypoffastric  point;  d'd',  mid-hypogastric  line;  e,e,  outer  border 
of  the  right  and  left  rectus  abdominis  ;  F.Monro's  point— on  the  fight  spino- 
umbilical  line  at  the  outer  border  of  tlie  rectus  abdominis. 

right  subphrenic  space  between  the  diaphragm 
and  liver ;  it  is  bounded  towards  the  middle  line 
by  the  falciform  and  coronary  ligaments;  below 
it  opens  into  the  subhepatic  space ;  (4)  left  sub- 
phrenic space,  between  the  diaphragm  above 
and   left  lobe  of  liver   and  stomach  below;  it  is 


364  SURGICAL    APPLIED    ANATOMY      [Part  IV 

separated  from  the  corresponding  right  space  by 
the  falciform  ligament ;  below  it  communicates  with 
(5)  the  perisplenic  space;  this  space  is  bounded 
below  by  the  splenic  flexure  and  its  mesocolon, 
the  left  costo-phrenic  ligament  and  left  kidney. 
These  five  spaces  lie  in  the  supra-omental  region 
of  the  abdomen — above  the  transverse  mesocolon ; 
below  the  transverse  mesocolon  there  are  two 
spaces,  normally  occupied  by  small  intestine;  (6) 
the  right  infra-omental,  bounded  above  by  the 
transverse  mesocolon,  below  and  to  the  left  by  the 
duodenojejunal  junction  and  root  of  the  mesen- 
tery ;  (7)  the  left  infra- omental,  bounded  above  by 
the  transverse  mesocolon;  it  is  separated  from 
the  right  space  by  the  duodenojejunal  junction 
and  mesentery  of  the  small  bowel.  The  remaining 
space — the  eighth — lies  in  the  pelvis,  the  recto- 
uterine in  the  female,  the  recto-vesical  in  the  male. 
Communications  between  the  supra-  and  infra- 
omental  spaces  exist  only  at  the  two  extremities 
of  the  transverse  mesocolon.  Overflow  from  the 
subhepatic  spaces  tends  to  pass  down  the  groove 
external  to  the  ascending  colon  (right  external 
paracolic  groove) ;  by  that  groove  it  reaches  the 
iliac  fossa ;  from  the  iliac  fossa,  the  pelvic  space ; 
from  the  pelvis  it  may  mount  to  the  left  infra- 
omental  pouch,  and  from  there  the  fluid  matter 
may  make  its  way  to  the  left  external  paracolic 
groove  and  thence  to  the  perisplenic  space.  In 
this  description  the  writings  of  Barnard,  Wallace, 
Box,  Jenkins,  and  Maynard  Smith  have  been 
followed. 

Surface  markings  of  the  abdominal  vis- 
cera.—In  Fig.  58  is  shown  the  position  of  the 
abdominal  viscera  in  an  average  individual,  while 
in  Fig.  59  is  represented  the  position  assumed  by 
these  viscera  in  a  well-marked  case  of  visceroptosis 
(Glenard's  disease).  Study  of  such  cases,  especi- 
ally by  the  aid  of  X-rays,  shows  the  need  of  an 
accurate  and  simple  method  of  indicating  the 
normal  position  of  the  abdominal  contents.  The 
upper  limit  of  the  viscera  is  best  indicated  bv  the 


Chap.  XVII] 


ABDOMINAL    VISCERA 


365 


sterno-ensiform  point  and  line.  The  position  of 
the  sterno-ensiform  point  is  indicated  by  a  dis- 
tinct depression  under  the  insertion  of  the  seventh 


Fig.  59. — Diagram  showing  the  position  of  the  viscera  in  the  condition 
of  visceroptosis. 

a,a,  [Sterno-ensiform  line :  it  crosses  above  the  fifth  costal  cartilage ;  b,b,  mid- 
epigastric  line ;  c,c,  umbilical  line ;  n,D,  mid-hypogastric  line  ;  a,  pericardium  : 
b,  stomach  (greatly  elongated  and  dilated)  ;  c,  liver  ;  c',  Riedel's  lobe  ;  d,  duo- 
denum ;  e,  CiBcum  ;  /,  transverse  colon  ;  g,  rectum  ;  h,  elongated  gastro-hepatic 
omentum. 

pair  of  costal  cartilages ;  the  sterno-ensiform  line 
is  drawn  transversely  on  the  body  through  this 
point  and  should  cross  the  fifth  pair  of  costal 
cartilages  if  the  thorax  is  of  normal  shape.  The 
right    dome    of   the    diaphragm,  in    the   standing 


366  SURGICAL    APPLIED    ANATOMY  LPart  IV 

posture,  reaches  this  line ;  the  left  dome  is 
£  an  inch  below  it;  in  the  supine  position 
the  domes  rise  upwards  ^  an  inch.  The  central 
tendon  is  \  an  inch  below  the  sterno-ensiform 
point.  In  visceroptosis  the  domes  of  the  dia- 
phragm and  viscera  within  them  sink  downwards 
until  they  lie  1  inch  or  more  below  their  normal 
position  (see  Fig.  59).  The  mid-epigastric  point 
is  taken  on  the  linea  alba  half-way  between  the 
umbilical  and  sterno-ensiform  points;  the  mid- 
epigastric  line  (transpyloric  plane  of  Addison) 
crosses  the  body  at  this  point;  it  marks  the  level 
of  the  pylorus,  pancreas,  with  the  beginning  and 
termination  of  the  duodenum  (Fig.  58).  In  vis- 
ceroptosis the  parts  sink  until  they  reach  the  um- 
bilical line  (Fig.  59).  The  umbilical  line,  drawn 
through  the  umbilicus,  usually  crosses  somewhat 
below  the  highest  point  on  the  iliac  crests ;  the 
transverse  colon  and  duodenum  cross  the  abdomen 
above  the  line,  the  bifurcation  of  the  aorta  is 
below  it.  In  visceroptosis  the  transverse  colon 
and  duodenum  descend  well  below  the  umbilical 
line  (Fig.  59).  The  mid-hypogastric  point  is  taken 
on  the  linea  alba  half  way  between  the  umbilicus 
and  symphysis  pubis;  it  lies  about  1  inch  below 
the  promontory  of  the  sacrum.  The  mid-hypo- 
gastric line  crosses  the  iliac  colon  in  the  left  groin 
and  the  fundus  of  the  caecum  in  the  right.  The 
outer  border  of  the  rectus  abdominis  (linea  semi- 
lunaris) also  serves  as  a  useful  guide ;  at  the  point 
where  it  crosses  the  costal  margin  on  the  right 
side  (right  costo-rectal  point)  is  situated  the  gall- 
bladder ;  on  the  left  side  the  greater  curvature  of 
the  stomach  emerges  from  the  hypogastrium  at 
this  point  (Fig.  58).  A  line  drawn  from  the 
umbilicus  to  the  right  anterior  superior  iliac  spine 
(spino-umbilical  line)  provides  a  useful  guide  to 
the  ileo-C83cal  region.  Monro's  point  is  situated 
on  this  line  at  the  outer  border  of  the  rectus 
abdominis ;  the  ileo-csecal  orifice  lies  to  the  right 
of  Monro's  point  immediately  below  the  spino- 
umbilical  line. 


Chap.  XVII]         ABDOMINAL    VISCERA  367 

The  viscera  arc  maintained  in  position 

by  the  action  of  several  structures,  but  by  far  the 
chief  are  the  muscles  of  the  abdominal  wall — the 
external  and  internal  oblique,  transversalis,  rec- 
tus abdominis,  diaphragm  and  levator  ani.  By 
their  contraction  or  tonus  they  maintain  the  vis- 
cera firmly  pressed  together ;  in  the  upright  pos- 
ture the  weight  of  the  upper  viscera  rests  on  the 
lower  viscera.  That  the  muscles  are  the  chief 
agents  in  maintaining  the  viscera  in  position  can 
be  shown  in  many  ways.  In  rising  from  the 
supine  to  the  upright  posture  the  upper  viscera 
and  diaphragm  are  seen  in  the  living  body  (by 
aid  of  X-rays)  to  descend  about  ^  an  inch.  When 
the  muscles  and  belly  walls  are  cut  away,  and  the 
dead  body  raised  to  the  upright  position,  all  the 
viscera  drop  downwards  to  the  extent  of  2  inches 
or  more.  The  peritoneal  ligaments,  reflections, 
omenta,  and  mesenteries  merely  limit  the  degree 
of  movement ;  the  viscera  are  freely  movable  to 
allow  the  extensive  respiratory  action  of  the  dia- 
phragm. Besides  the  peritoneal,  there  are  other 
visceral  supports  formed  by  vessels  and  their 
sheaths  of  connective  tissue,  such  as  the  attach- 
ment of  the  liver  to  the  diaphragm  by  the  in- 
ferior vena  cava,  the  kidneys  and  small  intestine 
to  the  posterior  abdominal  wall  by  their  vessels. 
It  is  only  when  the  muscles  of  the  belly  wall  are 
thrown  out  of  action  that  any  strain  or  weight 
falls  on  the  peritoneal  and  vascular  supports. 
The  stomach — Its  relationships  are  :— 

Above. 
Liver,  small  omentum,  diaphragm. 

Behind 

Li  front. 


(From  left  to  right)  dia- 
phragm, abdominal  wall, 
liver. 


Stomach. 


Transverse     -mesocolon, 
lesser      sac,       pancreas, 
crura,  solar  plexus,  great 
vessels,  spleen,  left  kid- 
ney, and  suprarenal. 
Below. 
Great  omentum,  small  intestines,  transverse  colon,  gastro-splenic 
omentum. 

m  The     oesophagus     perforates     the     diaphragm 
slightly  to  the  left  of  the  middle  line  and  ends  at 


368  SURGICAL    APPLIED    ANATOMY     [Part  IV 

the  cardiac  orifice  of  the  stomach,  3  to  4  inches 
deep  to  the  terminal  inch  of  the  seventh  left  costal 
cartilage.  The  pyloric  orifice,  permanently  closed 
by  its  sphincter  except  when  the  contents  of  the 
stomach  are  passing  to  the  duodenum,  is  situ- 
ated in  the  mid-epigastric  line,  about  half-way 
between  the  epigastric  point  and  the  right  costal 
margin  (Fig.  58).  Being  situated  under  the  quad- 
rate lobe  of  the  liver  and  bound  to  the  transverse 
fissure  by  the  gastro-hepatic  omentum,  enlarge- 
ment or  displacement  of  the  liver  necessarily 
causes  a  displacement  of  the  pylorus;  in  cases  of 
visceroptosis  it  may  drop  to  the  umbilical  line 
(Fig.  59).  Normally  the  lesser  curvature  is  over- 
lapped by  the  liver,  and  the  gastro-hepatic  omen- 
tum is  hid  (Fig.  58),  but  when  the  stomach  be- 
comes dilated,  elongated,  or  falls  down,  the  lesser 
curvature  and  gastro-hepatic  omentum  are  ex- 
posed (Fig.  59).  A  curved  line  drawn  from  the 
position  of  the  cardiac  orifice  (on  the  seventh 
costal  cartilage,  1  inch  from  the  sternum)  to  the 
position  of  the  pylorus  (mid-way  between  the  epi- 
gastric point  and  right  costal  margin)  indicates 
the  normal  position  of  the  lesser  curvature.  While 
the  lesser  curvature  is  comparatively  fixed,  owing 
to  the  attachment  of  the  gastro-hepatic  omentum, 
the  greater  curvature  is  freely  movable ;  its  posi- 
tion alters  as  the  stomach  is  full  or  empty,  con- 
tracted or  relaxed.  A  curved  line  drawn  from 
the  position  of  the  pylorus  to  the  left  costal  mar- 
gin, so  as  to  cross  the  linea  alba  2  inches  below 
the  mid-epigastric  line,  will  indicate  the  normal 
position  of  that  part  of  the  greater  curvature 
which  may  be  exposed  in  the  epigastric  space. 
Simple  dilatation  of  the  stomach  leads  to  a  low 
position  of  the  greater  curvature  without  altering 
the  position  of  the  lesser  curvature ;  in  ptosis  of 
the  stomach  both  curvatures  descend,  but  the 
greater  descends  most  owing  to  dilatation  being 
always  present  (Fig.  59).  In  ptosis  the  curva- 
tures become  more  vertical  in  position  (Fig. 
59).      The   shape  of   the   stomach   depends  on   the 


Chap.  XVII]        ABDOMINAL    VISCERA  369 

state  of  each  of  its  three  functional  divisions. 
The  fundus  lies  in  the  left  hypochondrium ; 
it  becomes  continuous  with  the  body  of  the 
stomach  at  or  just  abov3  the  left  subcostal 
margin  (Fig.  58);  the  body  joins  the  pyloric 
canal,  the  third  division,  about  \\  inch  from 
the  pyloric  orifice.  The  fundus  is  saccular  in 
form  and  serves  as  a  receptacle  for  the  food ;  it 
undergoes  no  active  movements ;  the  body,  on  the 
other  hand,  is  the  part  where  digestive  move- 
ments occur,  and  changes  in  shape  are  constantly 
taking  place,  but  it  is  always  more  or  less  tubular 
in  form.  When  empty  it  may  be  found  in  a  con- 
dition of  diastole  or  systole;  if  systolic  it  is 
usually  covered  by  the  transverse  colon,  and  does 
not  present  when  the  epigastrium  is  laid  open. 
The  two  extremities  of  the  stomach  are  its  most 
fixed  points.  The  cardiac  extremity  is  loosely 
fixed  to  the  diaphragm  by  the  oesophagus,  lax 
pericesophageal  tissue,  and  gastro-phrenic  reflec- 
tions of  peritoneum;  the  pyloric  end  is  fixed  to 
the  liver  and  posterior  abdominal  wall  by  the 
gastro-hepatic  omentum,  by  the  hepatic  branch  of 
the  coeliac  axis  and  the  tissue  surrounding  that 
vessel.  The  close  relations  of  the  stomach  to  the 
diaphragm  and  thoracic  viscera  serve  in  part  to 
explain  the  shortness  of  breath  and  possible  pal- 
pitation of  the  heart,  etc.,  that  may  follow  upon 
distension  of  the  organ  (Fig.  58,  p.  363).  The 
near  proximity  of  the  heart  to  the  stomach  is  illus- 
trated by  a  case  where  a  thorn  (of  the  Primus 
spinosa),  \  an  inch  long,  had  been  swallowed  and 
had  then  found  its  way  through  the  diaphragm 
and  pericardium  into  the  wall  and  cavity  of  the 
right  ventricle. 

The  viscus  is  susceptible  of  enormous  dilatation 
when  the  pylorus  is  obstructed.  The  distended 
organ  may  reach  as  low  as  Poupart's  ligament. 

The  stomach  rests  behind  on  the  lesser  sac  of 
the  peritoneum,  which  plays  the  part  of  a  bursa 
to  it.  Gastric  ulcers  rarely  perforate  into  the 
lesser  sac,  but  when  they  do  the  contents  can  only 

Y 


370  SUEGICAL    APPLIED    ANATOMY  [Part  IV 

escape  by  the  foramen  of  Winslow,  and  may  not 
be  seen  when  the  abdomen  is  opened.  The  sac 
is  opened  by  incising  the  great  omentum  at  the 
greater  curvature  of  the  stomach. 

The  stomach  has  been  frequently  wounded.  In 
most  cases  a  fatal  result  rapidly  follows  upon 
these  injuries,  for  the  contents  of  the  stomach 
escape  into  the  peritonea!  cavity  and  set  up  an 
acute  peritonitis.  The  most  certainly  and  rapidly 
fatal  cases,  therefore,  are  those  in  which  the 
stomach  was  full  of  food  at  the  time  of  the  acci- 
dent. The  empty  stomach,  being  deeply  placed 
and  lying  against  the  posterior  abdominal  wall  in 
a  collapsed  state,  is  but  little  exposed  to  injury. 
A  small  punctured  wound  of  the  stomach  need 
not  be  followed  by  escape  of  contents,  since  the 
loosely  attached  mucous  membrane  may  escape 
from  the  wound  and  effectually  plug  it.  This  was 
illustrated  many  times  in  the  Boer  war,  the  viscus 
having  been  perforated  by  a  Mauser  bullet.  The 
stomach  has  protruded  through  wounds  in  the 
abdominal  walls,  and  has  been  returned,  with  no 
evil  results  following.  In  a  few  cases  the  belly 
wall  in  front  of  the  stomach  has  been  wounded, 
the  viscus  has  protruded,  its  anterior  wall  has 
been  wounded  by  the  same  injury  that  penetrated 
the  parietes,  and  a  fistulous  opening  leading  into 
the  stomach  cavity  _  has  resulted.  The  best  ex- 
ample of  such  cases  is  afforded  by  the  well-known 
instance  of  Alexis  St.  Martin,  the  subject  of  so 
many  physiological  experiments.  In  this  man  the 
abdominal  parietes  in  front  of  the  stomach  were 
torn  away  by  a  gunshot  wound,  a  part  of  the  an- 
terior wall  of  the  stomach  sloughed,  and  a  per- 
manent fistula  resulted.  Dr.  Murchison  reports 
the  case  of  a  woman  in  whom  a  gastric  fistula 
was  produced  by  the  continued  pressure  of  a  cop- 
per coin  worn  over  the  epigastric  region.  This 
coin  was  deliberately  worn  by  the  patient  in  order 
to  excite  a  lesion  that  would  arouse  the  sympathy 
of  her  friends.  The  pressure  led  to  an  ulcera- 
tion that  finally  opened  up  the  stomach.     In  many 


Ohap.  XVII]        ABDOMINAL    VISCERA  371 

cases  the  fistula  has  been  due  to  ulcerative  diseases 
commencing  in  the  stomach  itself  and  spreading 
outwards. 

Some  remarkable  cases  have  been  recorded 
where  foreign  substances  have  been  swallowed  and 
have  lodged  in  the  stomach.  Certain  of  these 
cases  serve  to  illustrate  the  capacity  of  the 
stomach,  and  among  the  most  striking  is  an  in- 
stance where  the  viscus  at  death  was  found  to 
contain  thirty-one  entire  spoon-handles,  each 
about  5  inches  long,  four  half-handles,  nine  nails, 
half  an  iron  shoe-heel,  a  screw,  a  button,  and  four 
pebbles.  The  whole  mass  weighed  2  lb.  8  oz.  The 
patient  was  a  lunatic. 

The  pylorus  has  an  average  diameter  of  16  mm., 
about  that  of  a  sixpenny-piece.  It  is  normally  in 
a  closed  state,  and  should,  when  open,  be  capable 
of  taking  the  fore-finger.  In  spite  of  the  narrow- 
ness of  the  pylorus,  large  substances  that  have 
been  swallowed  have  been  passed  by  the  anus 
without  trouble.  Among  these  may  be  noted  a 
metal  pencil-case,  4|  inches  long,  10  ounces  of 
garden  nails,  and  fragments  of  crockery-ware 
swallowed  by  a  lunatic ;  a  fork,  a  door-key,  and 
other  strange  bodies.  Needles  and  similar  sharp 
substances  that  have  been  swallowed  have  travelled 
out  of  the  stomach  or  bowels  and  have  found 
their  way  to  the  surface  at  various  points  in  the 
body.  In  a  patient  under  my  care  at  the  London 
Hospital  I  extracted  from  beneath  the  skin,  near 
the  groin,  a  needle  swallowed  some  months  pre- 
viously. In  a  case  reported  in  the  Lancet  a  needle 
was  extracted  from  the  middle  of  the  thigh  six 
months  after  it  had  been  swallowed,  and  like 
instances  are  recorded  elsewhere. 

Hypertrophy  may  occur  in  the  pyloric 
sphincter  leading  to  a  functional  stenosis  of  the 
orifice.  It  occurs  soon  after  birth,  and  its  cause 
has  to  be  sought  for  in  the  reflex  mechanism  which 
regulates  it.  Relaxation  normally  follows  when 
the  chyme  expelled  from  the  stomach  has  been 
neutralised  in  the  duodenum. 


372  SURGICAL    APPLIED    ANATOMY  [Part  IV 

The  lymphatics  of  the  stomach  pass  mostly 
to  the  glands  situated  between  the  layers  of 
the  small  omentum  along  the  lesser  curvature. 
Some  also  pass  to  the  glands  scattered  along 
the  greater  curvature  of  the  stomach.  In  can- 
cer of  the  pylorus,  the  glands  along  the  lesser 
curvature  are  the  first  t6  become  affected,  and 
from  these  the  disease  spreads  along  vessels  which 
accompany  the  coronary  artery  of  the  stomach  to 
the  coeliac  glands  near  the  commencement  of  the 
thoracic  duct.  Lymphatics  also  pass  from  the 
pylorus  to  the  coeliac  glands  along  the  curve  of 
the  pyloric  and  hepatic  arteries.  Owing  to  a 
free  communication  between  the  lymphatics  of  the 
pylorus,  pancreas,  and  liver,  the  disease  fre- 
quently involves  these  organs. 

Oastrotosny  and  gastrostomy. — Gastrotomy 
consists  in  opening  the  stomach  through  the  an- 
terior abdominal  wall  for  the  purpose  of  removing 
a  foreign  body,  for  making  an  examination,  or 
for  dealing  with  a  simple  or  malignant  ulcer ; 
gastrostomy,  in  opening  the  stomach  in  a  like 
situation  with  the  object  of  establishing  a  gastric 
fistula  through  which  the  patient  may  be  fed  in 
cases  where  the  gullet  is  occluded  by  disease.  The 
uncovered  part  of  the  stomach,  accessible  in  these 
operations,  is  represented  by  a  triangular  area, 
bounded  on  the  right  by  the  edge  of  the  liver,  on 
the  left  by  the  cartilages  of  the  eighth  and  ninth 
ribs,  and  below  by  a  horizontal  line  passing  be- 
tween the  tips  of  the  tenth  costal  cartilages  (Fig. 
58).  In  the  empty  condition  five-sixths  of  the 
stomach  lies  beneath  the  left  hypochondriac  region, 
only  part  of  the  pyloric  end  being  exposed  in  the 
triangular  area.  The  incision  in  these  operations 
must  be  situate  in  this  triangle,  and  may  be  made 
either  parallel  to,  and  about  two  fingers'  breadth 
from,  the  free  border  of  the  costse,  or  along  the 
left  semilunar  line.  In  the  former  incision  the 
three  flat  muscles  of  the  abdomen  are  cut  through. 
In  gastrostomy  the  stomach  is  not  opened  at  the 
time  of  the  operation,  but  is  merely  secured  to  the 


Chap.  XVII]        ABDOMINAL    VISCERA  373 

wound,  and  a  few  days  are  then  allowed  to  elapse 
so  that  adhesions  may  (orm.  At  the  end  of  this 
time  the  viscus  is  opened.  The  opening  must 
needs  be  very  small. 

Resection  of"  the  pylorus. — The  pylorus  is 
frequently  the  seat  of  cancer.  As  a  means  of  re- 
lieving the  patient,  the  whole  of  the  diseased 
pylorus  has  been  removed,  and  the  divided  ends 
of  the  stomach  and  duodenum  united  by  sutures. 
The  situation  of  the  cancerous  pylorus  within  the 
abdomen  varies  considerably,  as  the  diseased  part 
is  very  apt  to  shift  its  position.  It  is  often  found 
to  have  sunk  down  by  its  weight  to  a  point  below 
the  umbilicus,  and  to  have  contracted  adhesions 
to  adjacent  organs.  The  diseased  part  has  to  be 
isolated  and  the  omental  connections  of  the  right 
end  of  the  stomach  freely  divided.  The  vessels 
that  are  almost  certainly  divided  are  the  pyloric, 
the  gastro-epiploica  dextra,  and  the  gastro-duo- 
denal.  The  operation  has  not  been  attended  with 
much  success.  The  cancer  is  apt  to  become  diffuse, 
to  spread  to  adjacent  tissues,  and  to  lead  to  early 
lymphatic  invasion  of  the  greater  and  lesser 
omenta. 

Oastrectomy. —  Considerable  portions  of  the 
stomach  have  been  excised  in  cases  of  cancer,  and 
the  entire  organ  has  been  removed  (total  gastrec- 
tomy) for  the  same  cause.  Up  to  the  time  of 
writing  some  fifteen  examples  of  this  operation 
have  been  recorded  with  more  or  less  imme- 
diate death  in  five.  Schlatter's  first  case  of  gas- 
trectomy, performed  in  1897,  died  in  fourteen 
months  from  secondary  deposits.  Ricord  pub- 
lished a  case  in  which  he  removed  the  whole 
stomach,  the  first  piece  of  the  duodenum,  and 
part  of  the  pancreas.  The  patient  was  alive  and 
well  eleven  months  after  the  operation  (Gaz.  des 
Hopitaux,  March  22nd,  1900).  It  has  yet  to  be 
shown  that  the  operation  is  of  genuine  value. 
There  is  difficulty  in  uniting  the  gullet  to 
the  small  intestine ;  both  vagi  nerves  are  divided 
as  they  emerge  through  the  diaphragm,   and  the 


374  SURGICAL    APPLIED    ANATOMY  [Part  IV 

solar  plexus  is  apt  to  be  roughly  handled ;  the 
operation  is  an  extreme  test  for  a  weakened 
patient,  and  the  after  condition  of  those  who 
survive  is  not  free  from  distress.  There  is,  how- 
ever, less  disturbance  of  digestion  than  would  be 
imagined. 

Other  operations  on  the  stomach. — 
Many  other  operations  are  performed  upon  the 
stomach  which  call  merely  for  mention  in  this 
place.  One  of  the  most  useful  and  the  most  fre- 
quently performed  is  gastroenterostomy.  Here 
an  opening  (or  stoma)  is  made  between  the 
stomach  and  the  upper  part  of  the  jejunum.  An 
opening  has  also  to  be  made  in  the  transverse 
mesocolon  in  order  that  the  bowel  may  be  applied 
to  the  posterior  aspect  of  the  stomach.  In  making 
the  opening  the  middle  colic  artery  and  its  larger 
branches  are  to  be  avoided.  The  operation  is  per- 
formed in  cases  of  stenosis  of  the  pylorus,  in 
cases  of  dilatation  of  the  stomach  without  much 
stenosis,  in  certain  examples  of  ulcer,  and  in 
many  other  conditions.  In  the  operation  of 
pyloroplasty,  a  non-malignant  stricture  of  the 
pylorus  is  divided  and  the  pyloric  passage  thus 
made  free.  In  gastroplication  certain  conditions 
of  dilated  stomach  are  dealt  with  by  taking  in  a 
fold  or  pleat  in  the  stomach  wall  and  in  thus 
lessening   its  capacity. 

The  small  intestines.* — The  average  length 
of  the  small  intestine  in  the  adult  is  22^  feet,  the 
extremes  being  30  feet  and  15  feet,  the  length,  to 
a  considerable  extent,  depending  on  the  degree 
of  contraction  of  the  longitudinal  muscular  coat. 
In  the  foetus,  at  full  term,  the  lesser  bowel  mea- 
sures about  9j  feet.  It  is  roughly  reckoned  that 
the  first  8  or  9  feet  of  the  adult  bowel  belongs  to 
the  jejunum,  and  the  remaining  12  or  13  feet  to 
the  ileum. 

The  division  into  jejunum  and  ileum  is  quite 
arbitrary.     There   is  no  one   point  where   it  can 

*  The  account  of  the  intestines  is  derived  from  the  Author's  work  "On 
the  Intestinal  Canal  and  Peritoneum  in  Man."     London.     1885. 


Chap.  XVIIJ       ABDOMINAL    VISCERA  375 

be  said  that  the  jejunum  ends  and  the  ileum 
commences.  When  the  small  intestines  are  ex- 
posed by  accident  or  operation,  it  is  often  diffi- 
cult, especially  when  there  is  abdominal  disease, 
to  recognise  the  upper  from  the  lower  part  of  the 
gut.  It  may  be  noted,  however,  that  the  jejunum 
is  wider  than  the  ileum  (its  diameter  being  £  of  an 
inch  greater  than  that  of  the  ileum),  and  its 
coats  are  thicker  and  more  vascular.  If  the  gut 
be  empty,  and  can  be  rendered  translucent  by 
being  held  against  a  light,  the  lines  of  the  valvulse 
conniventes  can  be  well  seen.  These  folds  are 
large  and  numerous  in  the  jejunum,  but  become 
small  and  scanty  in  the  upper  ileum,  and  are 
wanting  in  the  lower  third  of  that  bowel.  In- 
juries of  the  jejunum  are  more  serious  than 
are  those  of  the  ileum,  since  an  intestinal  lesion 
is  (other  things  being  equal)  the  more  serious  the 
nearer  it  approaches  to  the  stomach.  The  fatality 
of  umbilical  hernise  probably  depends  in  part 
upon  the  fact  that  the  contained  bowel  is  often 
jejunum.  The  coils  of  small  intestine  occupy  no 
certain  position  in  the  abdomen.  In  the  foetus, 
and  during  the  earliest  part  of  extra-uterine  life, 
the  bulk  of  the  small  intestine  is  placed  to  the  left 
of  the  middle  line.  This  is  on  account  of  the  re- 
latively large  size  of  the  liver,  to  the  weight  of 
which  the  lesser  bowel  no  doubt  acts  as  a  counter- 
poise. In  the  majority  of  adult  bodies  the  small 
intestine  is  disposed  in  an  irregularly  curved 
manner  from  left  to  right.  The  gut,  starting 
from  the  duodenum,  will  first  occupy  the  contigu- 
ous parts  of  the  left  side  of  the  epigastric  and 
umbilical  regions ;  the  coils  then  fill  some  part  of 
the  left  hypochondriac  and  lumbar  regions;  they 
now  commonly  descend  into  the  pelvis,  re-appear 
in  the  left  iliac  quarter,  and  then  occupy  in  order 
the  hypogastric,  lower  umbilical,  right  lumbar, 
and  right  iliac  regions.  Before  reaching  the  lat- 
ter situation  they  commonly  descend  again  into 
the  pelvis. 

Much   interest   attaches   to   the   coils   of   small 


376  SURGICAL    APPLIED    ANATOMY  [Part  IV 

intestine  that  are  found  in  the  pelvis.  These  are 
the  coils  that  are  apt  to  become  involved  and  ad- 
herent in  cases  of  pelvic  peritonitis,  and  that 
would  probably  form  the  protrusion  in  most  cases 
of  obturator,  sciatic,  and  pudendal  hernia.  No 
small  intestine  occupies  the  foetal  pelvis.  The 
amount  found  in  the  adult  pelvis  depends  mainly 
upon  the  state  of  distension  of  the  bladder  and 
rectum,  and  upon  the  position  of  the  sigmoid 
flexure.  The  coils  that  are  most  usually  found 
in  this  position  belong  to  the  terminal  part  of  the 
ileum,  and  to  that  part  of  the  intestine  that  has 
been  already  alluded  to  as  possessing  the  longest 
mesentery  ^  (page  360).  The  ileum  is  the  part  of 
the  intestine  that  is  most  frequently  found  in 
inguinal  and  femoral  hernise.  It  is  also  the  part 
most  usually  involved  in  cases  of  strangulation 
by  internal  bands,  by  holes  in  the  mesentery,  etc. 
Of  all  the  viscera  the  small  intestines  are  the 
most  exposed  to  injury,  and  at  the  same  time  it 
must  be  noted  that  by  their  elasticity,  and  by  the 
ease  with  which  their  coils  slide  over  one  another 
and  so  elude  the  effects  of  pressure,  they  are  the 
best  adapted  to  meet  such  injuries  as  contusions 
and  the  like.  A  minute  punctured  wound  of  the 
small  gut  does  not  lead  to  extravasation  of  con- 
tents. The  muscular  coat  contracts  and  closes  the 
little  opening.  Thus,  in  excessive  tympanitis  the 
bowels  are  often  freely  punctured  in  many  places 
with  a  fine  capillary  trochar,  to  allow  the  gas  to 
escape,  without  any  evil  resulting.  A  case  of  in- 
testinal obstruction  of  sixteen  weeks'  duration 
is  reported,  in  which  the  abdomen  was  punctured 
150  times  {Boston  Med.  Journ.).  If  the  wound 
be  a  little  larger  the  loose  mucous  membrane  be- 
comes everted  or  protruded  through  the  wound 
and  effectually  plugs  it.  Gross  found  that  a 
longitudinal  cut  in  the  small  bowel  2^  lines  in 
length  was  immediately  reduced  to  a  wound  If 
lines  in  length  by  muscular  contraction,  and  that 
the  eversion  of  the  mucous  membrane  in  addi- 
tion to  this  contraction  entirely  sealed  the  open- 


Chap.  XVII]        ABDOMINAL   VISCERA  377 

ing.  Even  the  opening  made  in  the  intestine — 
for  example,  in  the  jejunum — by  the  penetration 
of  a  Mauser  bullet  may  be  attended  by  no  escape 
of  contents.  A  contracted  empty  piece  of  bowel 
becomes  nearly  twice  as  long  when  distended. 

Owing  to  the  greater  power  of  the  circular 
layer  of  muscle  a  longitudinal  wound  gapes  more 
than  a  transverse  wound,  and,  in  consequence  of 
the  greater  muscular  development  of  the  jejunum, 
wounds  of  that  part  gape  more  than  do  those  of 
the  ileum.  Transverse  wounds  gape  most  when 
inflicted  across  the  free  border  of  the  gut,  since 
in  that  place  the  longitudinal  muscular  fibres 
are  thickest. 

In  one  remarkable  case  a  man  was  stabbed  in 
the  belly.  It  was  subsequently  found  that  there 
was  a  small  puncture  in  the  ileum,  which  had  been 
plugged  by  the  mucous  membrane  and  further 
secured  by  recent  lymph.  The  man  did  well  until 
the  fourth  day,  when  he  died  somewhat  suddenly. 
It  was  then  found  that  an  intestinal  worm 
(Ascaris  lumbricoides)  had  worked  its  way 
through  the  wound,  breaking  down  the  adhesions, 
and  had  escaped  into  the  peritoneal  cavity.  Ex- 
travasation followed,  and  thus  the  worm  was  the 
immediate   cause   of  the   man's   death. 

The  calibre  of  any  portion  of  the  small  in- 
testine depends  mainly  upon  the  condition  of  its 
muscular  wall.  The  tube  may  become  much  con- 
tracted when  empty.  In  peritonitis  and  in  cer- 
tain other  conditions  the  muscular  coat  is  para- 
lysed and  the  bowel  becomes  intensely  dilated  by 
gas   (tympanites). 

Meckel's  diverticulum. — From  one  to  four 
feet  from  the  end  of  the  ileum  is  sometimes  seen 
a  diverticulum  (Meckel's)  that  represents  the 
remains  of  the  vitello-intestinal  duct  (p.  329). 
It  may  be  expected  in  2  per  cent,  of  the  bodies 
examined.  This  diverticulum  usually  exists  as  a 
tube  of  the  same  structure  as  the  intestine.  Its 
length  varies.  It  may  sometimes  extend  as  a 
patent  tube  as  far  as  the  umbilicus.     It  is  more 


378  SURGICAL    APPLIED    ANATOMY   [Part  IV 

often  but  a  few  inches  long,  and  may  then  end 
in  a  free  conical  or  globular  extremity,  or  in  a 
fibrous  cord.  This  diverticulum  may  cause  in- 
testinal obstruction  in  many  ways.  Its  end  may 
contract  adhesions,  and  beneath  the  bridge  thus 
formed  a  loop  of  bowel  may  be  strangled.  It  may 
twist  itself  about  a  piece  of  intestine  so  as  to 
form  a  knot  round  it.  It  may,  from  its  adhesions, 
so  drag  upon  the  ileum  as  to  cause  "  kinking  ;; 
of  the  tube  at  its  point  of  origin.  In  more  than 
one  case  it  has  been  found  in  an  external  hernia. 
It  may  become  invaginated  and  start  an  intussus- 
ception of  the  bowel.  The  lumen  of  the  gut  is 
often  considerably  diminished  at  or  near  the  site 
of  the  diverticulum,  and  at  this  narrowing  in- 
tussusception of  the  bowel  may  commence. 

The  duodenum  and  fossa  duodeno- 
jejunal! s.— The  first  portion  of  the  duodenum  is 
nearly  horizontal.  It  measures  about  2  inches  in 
length  and  passes  backwards  from  the  pylorus  to 
near  the  upper  end  of  the  right  kidney.  The 
second  portion,  about  3  inches  in  length,  descends 
vertically  in  front  of  the  inner  border  of  the 
right  kidney  to  the  level  of  the  third  lumbar 
vertebra.  The  third  portion,  some  5  inches  in 
length,  crosses  from  right  to  left  in  front  of  the 
third  vertebra,  and  then  ascends  for  a  short  dis- 
tance on  the  surface  of  the  left  psoas  muscle,  to 
end  in  the  jejunum  to  the  left  of  the  second 
lumbar  vertebra  (Fig.  58,  p.  363).  The  first  por- 
tion, which  is  movable,  is  invested  by  peritoneum 
in  the  same  manner  as  the  stomach.  The  second 
part  is  covered  by  peritoneum  in  front  only,  ex- 
cept at  the  spot  where  it  is  crossed  by  the  trans- 
verse colon.  The  third  part  is  also  covered  by 
peritoneum  on  its  anterior  aspect  only,  this  mem- 
brane being,  however,  free  of  the  gut  where  the 
superior  mesenteric  vessels  cross  it.  A  constric- 
tion, probably  functional  in  nature,  is  usually 
found  at  the  termination  of  the  third  stage. 

The  end  of  the  duodenum,  the  duodeno- 
jejunal bend,   is  very  firmly  held  in   place  by   a 


Chap.  XVII]       ABDOMINAL    VISCEEA  379 

band  of  fibrous  tissue  that  descends  upon  it  from 
the  left  crus  of  the  diaphragm  and  the  tissue 
about  the  coeliac  axis.  This  band  is  called  the 
suspensory  muscle  of  the  duodenum  (Treitz).  It 
serves  also  to  support  the  mesentery.  In  ptosis  of 
the  viscera  the  neck  of  the  pancreas  and  duodeno- 
jejunal bend  are  the  least  displaced  parts  be- 
cause of  their  attachment  to  the  posterior  wall  by 
the  fibrous  tissue  round  the  cceliac  axis  and  origin 
of  the  superior  mesenteric  artery.  All  sections  of 
the  duodenum  have  been  ruptured  by  violence. 
Owing  to  its  large  non-peritoneal  surface,  the 
bowel,  if  approached  from  behind,  may  be 
wounded   without   opening   the   peritoneum. 

Brunner's  glands  occur  in  the  first  stage  of  the 
duodenum;  their  secretion  probably  protects  this 
part  of  the  gut  against  the  acid  chyme  which 
is  only  neutralised  as  it  reaches  the  second  stage. 
It  is  probably  because  of  the  nature  of  its  con- 
tents that  the  first  stage  of  the  duodenum  is  so 
frequently  the  site  of  ulceration ;  over  90  per  cent, 
of  duodenal  ulcers  occur  in  the  first  stage  (Collin). 
The  ulcer  may  perforate  and  the  contents  escape 
into  the  subhepatic  space,  or  adhesions  may  form 
to  surrounding  organs — the  gall  bladder,  the  liver, 
the  head  of  the  pancreas,  the  right  kidney,  or  the 
hepatic  flexure  of  the  colon.  A  diverticulum  is 
frequently  found  just  above  the  entrance  of  the 
common  bile  duct  (Rolleston),  especially  in  cases 
of  ptosis.  Congenital  constrictions  of  the  duo- 
denum occur. 

Passing  from  the  front  of  the  terminal  (as- 
cending) part  of  the  duodenum^  a  fold  of  peri- 
toneum is  often  seen,  that  joins  the  parietal 
peritoneum  to  the  left  of  the  piece  of  gut  in  ques- 
tion. This  fold  marks  off  a  fossa  of  triangular 
outline,  the  orifice  of  which  is  directed  upwards. 
I  have  found  the  fossa  in  about  50  per  cent,  of 
the  bodies  examined.  It  is  called  the  fossa 
diiodeiio-jejmialis ;  it  is  usually  large  enough 
to  lodge  the  tip  of  the  finger,  and  its  opening  lies 
just    below    the    duodeno-jejunal    bend    (Fig.    60). 


380 


SURGICAL    APPLIED    ANATOMY  [Part  IV 


This  fossa  is  the  anatomical  cause  of  mesen- 
teric^ mesocolic,  meso gastric,  or  retroperitoneal 
hernia.  The  commencement  of  the  jejunum  presses 
into  the  fossa,  enlarges  its  cavity,  and  ultimately 
separates  the  peritoneum  from  its  posterior  at- 
tachments. More  and  more  of  the  small  intestine 
passes  into  the  increasing  pouch,  until  at  last,  as 
in  the  case  reported  by  Sir  Astley  Cooper  and  in 
many  others,  nearly  the  whole  of  the  small  intes- 


ferioh^meseWteriicmein 

W  &s-       li  lib  ~ 


DUODENAL  FOLD 


Fig.  60.— The  fossa  duodenojejunalis.     (Treves.) 

tine  may  be  found  lodged  in  an  enormous  median 
retroperitoneal  sac,  the  mouth  of  which  is  the 
orifice  of  the  fossa  duodeno-jejunalis.  The  duo- 
denum can  be  seen  to  enter  the  sac  and  the  end 
of  the  ileum  to  leave  it.  The  sac  usually  extends 
downwards  on  the  left  side,  and  may  reach  the 
promontory  of  the  sacrum.  These  hernise  vary  in 
size,  but  are  as  a  rule  large.  The  caecum  and 
ascending  colon  have  their  normal  position,  but 
the  transverse  and  descending  parts  of  the  colon 
are  stretched  over  and  displaced  by  the  sac.     The 


Chap.  XVII]       ABDOMINAL    VISCERA  381 

renal  artery  is  behind  the  hernia,  and  the  in- 
ferior mesenteric  artery  is  in  front  of  it  and  to 
the  left.  A  branch  of  this  vessel,  the  colica  sinis- 
tra, is  near  to  the  orifice  of  the  sac  in  its  lower 
part.  Numerous  modifications  occur  in  the  form 
and  boundaries  of  this  peritoneal  fossa,  and  a 
hernia  may  enlarge  in  any  direction,  but  usually 
towards  the  left,  where  it  passes  behind  a  peri- 
toneal fold  containing  the  inferior  mesenteric 
vein. 

Operations  on  the  small  intestine. — Enter- 
otomy  is  the  operation  of  opening  the  small  in- 
testine above  some  obstruction  that  threatens  to  be 
fatal  or  insuperable.  An  incision  is  made  in  the 
linea  alba,  below  the  umbilicus,  or  in  one  or  other 
iliac  region,  as  is  considered  more  convenient. 
This  if  some  2  or  3  inches  in  length  will  prob- 
ably suffice.  The  peritoneum  having  been  opened, 
a  knuckle  of  small  bowel  close  above  the  ob- 
struction is  seized,  secured  to  the  parietal  wound, 
and  then  opened.  The  small  intestine  has  also 
been  opened  to  remove  impacted  foreign  bodies 
and  large  gall  stones.  In  such  cases  the  intes- 
tinal wound  is  usually  closed  immediately. 

E uterectomy. — Parts  of  the  small  intestine  have 
been  resected  with  success  for  various  diseased 
conditions.  In  one  case  more  than  two  yards  of 
the  small  intestine  was  cut  away  on  account  of 
multiple  stricture.  The  patient,  a  young  woman, 
made  an  excellent  recovery.  Resections  have  also 
been  successfully  performed  in  cases  of  bullet 
wound  or  stab  involving  the  lesser  bowel,  and  in 
other  injuries.  Tumours  of  the  gut  have  been 
removed  by  a  partial  resection.  Non-malignant 
strictures  of  the  bowel  have  been  treated  by  in- 
cision and  dilatation. 

The  bowel  above  an  obstruction  has  been  con- 
nected to  the  bowel  below  an  obstruction  by  the 
operation  called  intestinal  anastomosis  or  short 
circuiting,  « 

In  uniting  divided  intestine  by  suture  (enter- 
oraphy)  it  is  essential  that  the  serous  coat  of  the 


382  SUEGICAL    APPLIED    ANATOMY   [Part  IV 

ends  of  the  bowel  should  be  brought  together. 
This  is  best  effected  by  the  suture  known  as  Lem- 
bert;s,  with  the  addition  of  a  special  and  separate 
line  of  sutures  for  the  mucous  membrane.  Ex- 
perience shows  that  if  leakage  occurs  after  re- 
section or  suture  of  intestine  it  will  most  likely 
occur  along  the  attachment  of  the  mesentery. 
This  circumstance  is  thus  explained  by  Mr.  An- 
derson :  The  two  layers  of  the  mesentery  diverge 
as  they  approach  the  bowel,  and  so  leave  a  tri- 
angular space,  the  base  of  which,  averaging  about 
1%  ths  of  an  inch  in  width,  is  formed  by  the  un- 
covered muscular  tissue.  It  is  the  existence  of 
this  bare  piece  of  intestine  that  renders  adjust- 
ment of  the  serous  coat  at  the  attachment  of  the 
mesentery  a  matter  of  some  difficulty. 

The  ileo-cseeal  region. — The  caecum  is,  to  a 
certain  extent,  rudimentary  in  man,  as  it  is  also 
in  the  carnivora.  In  herbivorous  animals  it  is  of 
great  size,  and  appears  to  serve  as  a  reservoir  for 
the  elaboration  and  absorption  of  food.  It  has 
been  said  that  the  caecum  in  man  exists  as  an 
anatomical  protest  against  vegetarianism.  The 
appendix  persists  as  the  remains  of  the  larger 
caecum  of  lower  mammals.  In  the  human  foetus 
it  can  be  seen  to  be  but  the  narrowed  ex- 
tremity of  a  capacious  caecum.  The  foetal  type 
of  caecum,  which  is  very  characteristic,  may  per- 
sist throughout  life.  From  the  point  of  view  of 
evolution  the  appendix  would  appear  to  be  becom- 
ing obliterated.  Like  other  functionless  parts 
that  persist  as  developmental  relics,  it  is  very  fre- 
quently the  seat  of  disease,  and  it  is  worthy  of 
note  that  such  disease  tends  to  cause  the  entire 
obliteration  of  the  part  (as  after  many  forms  of 
so-called  appendicitis). 

It  must  be  understood  that  the  term  ccecum  is 
applied  to  that  part  of  the  colon  that  lies  below 
the  entrance  of  the  ileum.  The  average  breadth 
of  the  adult  caecum  is  3  inches,  its  average  length 
(vertical  measurement)  2|  inches.  The  caecum 
normally   contains   gas,    and   gives   a   high,    tym- 


Chap.  XVII 1        ABDOMINAL   VISCERA 


383 


panitic  note  on  percussion ;  Glenard  found  that  in 
cases  of  ptosis  of  the  viscera  it  was  often  con- 
tracted, and  when  palpated  had  the  consistency 
of  a  sausage. 

The  caecum  is  usually  lodged  in  the  right  iliac 
fossa,  and  is  so  placed  that  its  apex  corresponds 
with  a  point  a  little  to  the  inner  side  of  the 
middle  of  Poupart;s  ligament.  When  distended 
with  gas  or  faecal  contents  it  occupies  the  whole 
of  the  right  iliac  fossa.  The  ileo-caecal  orifice  is 
situated    immediately    below    the    spino-umbilical 


MESO  COLON 


ILEOCOLIC  FOSSA 


BLOODLESS  FOLD 


REXROCAECAL 

ILEOCECAL  FOSSA 

Fig.  61. — The  peritoneal  fossae  of  the  ileo-cEecal  region. 


line  and  externally  to  Monro's  point  {see  Fig.  58, 
p    363). 

A  slightly  distended  caecum  so  located  may  be 
emptied  by  flexing  the  thigh  upon  the  abdomen. 
The  caecum  is  always  entirely  invested  by  peri- 
toneum. Its  posterior  surface  is  never  in  con- 
nection with  the  areolar  tissue  of  the  iliac  fossa. 
The  peritoneum  is  reflected  from  the  commence- 
ment of  the  ascending  colon  on  to  the  posterior 
parietes  below  the  level  of  the  iliac  crest.  A 
mobile  caecum  may  hang  over  the  pelvic  brim,  or 
occupy  the  pelvis,  or  even  find  its  way  into  an 
inguinal  hernia  of  the  left  side.  The  caecum  is 
not  unfrequently  found  in  an  inguinal  or  femoral 


384  SUKGICAL    APPLIED    ANATOMY  [Part  IV 

hernia  of  right  side  (csecal  hernia).  Such  herniae 
are,  except  in  a  few  rare  instances,  provided  with 
a  proper  and  complete  peritoneal  sac.  Foreign 
bodies  that  have  been  swallowed  are  very  apt  to 
lodge  in  the  caecum,  and  in  that  situation  may 
cause  ulceration  and  even  perforation  of  the 
bowel,  producing  one  form  of  typhlitis.  In  cases 
of  faecal  retention,  also,  'the  largest  accumulation 
of  faecal  matter  is  very  usually  met  with  in  the 
caecum,  and  upon  that  part  of  the  bowel  when 
distension  is  extreme  the  greatest  strain  usually 
comes.  Stercoral  ulcers  (ulcers  due  to  the  pres- 
sure and  irritation  of  retained  faeces)  are  more 
often  met  with  in  the  caecum  than  in  any  other 
part  of  the  colon.  Solitary  follicles  are  numerous 
in  the  mucous  membrane  of  the  caecum,  especially 
near  the  ileo-caecal  orifice.  Intestinal  concretions 
also  are  not  uncommon  in  this  part. 

The  caecum  is  susceptible  of  enormous  disten- 
sion, provided  that  this  be  gradually  effected,  and, 
in  certain  instances,  a  dilated  caecum  has  been 
found  to  occupy  a  large  part  of  the  abdominal 
cavity.  When  the  abdomen  is  opened  in  any 
doubtful  case  of  intestinal  obstruction,  the  con- 
dition of  the  caecum  is  of  great  value  in  pointing 
to  the  seat  of  the  obstacle.  In  stenosis  of  the 
colon  it  will  be  found  greatly  distended,  while  in 
obstruction  of  the  small  gut  it  will  be  empty,  or, 
at  least,  in  a  normal  condition. 

Three  kinds  of  movement  occur  in  the  caecum  : 
(1)  a  churning  movement,  which  has  been  ob- 
served to  commence  within  an  hour  of  taking 
food ;  (2)  antiperistaltic  movements  which  begin 
in  the  colon  and  end  in  the  caecum;  (3)  pro- 
pulsive or  emptying  movements.  Water  is  ab- 
sorbed, and  the  faeces  commence  to  assume  a  solid 
consistency  as  they  reach  the  transverse  colon. 
The  ileo-caecal  orifice  is  guarded  by  a  muscular 
sphincter  (ileo-ccecal  sphincter) ;  it  is  innervated 
by  the  sympathetic  system  and  regulates  the 
escape  of  chyme  from  the  ileum  (Elliot  and  B. 
Smith) ;  MacEwen  has  seen  it  in  action  in  the  case 


Chap.  XVII]        ABDOMINAL    VISCERA  385 

of  a  soldier  in  whom  a  wide  caecal  fistula  resulted 
from  a  gunshot  injury.  MacEwen  also  observed 
a  secretion  escaping  from  the  mouth  of  the  appen- 
dix, which  is  situated  about  1  inch  below  the 
ileo-csecal  orifice. 

The  appendix  varies  in  length.  Its  average 
measurement  in  the  adult  is  4  inches,  the  extremes 
being  1  inch  and  6  inches.  Its  position  varies, 
although,  as  a  rule,  it  is  seen  to  lie  behind  the 
end  of  the  ileum  and  its  mesentery,  and  to  point 
in  the  direction  of  the  spleen.  It  frequently  also 
lies  behind  the  caecum.  I  have  seen  the  appendix 
so  placed  with  reference  to  the  bowel  that  it  would 
have  been  encountered  in  a  right  lumbar  colotomy. 
In  such  cases  the  appendix  has  been  pushed  be- 
hind the  caecum  and  caught  in  the  mesocolon 
during  the  later  months  of  foetal  life,  when  the 
colon  migrates  from  the  neighbourhood  of  the 
liver  to  the  right  iliac  fossa.^  The  appendix  may 
hang  within  the  pelvis  and,  in  inflammatory  con- 
ditions, contract  adhesions  to  the  ovary  or  other 
pelvic  structures.  I  have  found  an  inflamed  ap- 
pendix adherent  to  the  liver  and  another  in  the 
left  iliac  fossa.  It  has  found  its  way  down  both 
the  right  and  the  left  inguinal  canals. 

The  tip  of  the  process  may  adhere  to  a  neigh- 
bouring peritoneal  surface,  and  thus  forin  a 
"  band,"  beneath  which  a  piece  of  small  intestine 
may  be  strangulated. 

Foreign  bodies  occasionally  lodge  in  the  ap- 
pendix, and  it  is  very  often  found  to  be  occupied 
by  a  faecal  concretion  or  calculus.  These  sub- 
stances excite  inflammation,  and,  as  a  result,  the 
appendix  may  become  perforated.  Troubles  in 
the  vermiform  process  are  the  most  frequent 
causes  of  perityphlitis,  a  term  applied  to^  localised 
inflammation  of  the  peritoneum  in  the  vicinity  of 
the  caecum. 

The  mesentery  of  the  appendix  (Fig.  61),  whiph 

contains    an    artery    derived   from   the    ileo-colic, 

may  be  so  short  as  to  produce  obstructive  kinks 

in  the  appendix.    The  mucous  lining  is  so  crowded 

z 


386  SURGICAL   APPLIED    ANATOMY       [Part  IV 

with  solitary  lymphoid  follicles  as  almost  to  oc- 
clude its  lumen.  Like  other  lymphoid  structures 
these  follicles  begin  to  atrophy  soon  after  adult 
life  is  reached.  In  some  forms  of  appendicitis 
these  follicles  are  involved.  They  are  surrounded 
by  lymph  spaces,  from  which  vessels  pass  to  the 
lymph  glands  in  the  mesentery,  especially  to  a 
group  situated  in  the  ileo-colic  angle — the  ileo- 
colic group ;  others  pass  upwards  behind  the  as- 
cending colon  (Lockwood).  It  is  probably  through 
these  latter  vessels  that  infection  passes  from  the 
appendix  and  gives  rise  to  abscesses  in  the  sub- 
diaphragmatic region.  The  muscular  coat  of  the 
appendix  is  scanty,  and  through  breaks  in  it  the 
submucous  tissue  communicates  with  the  sub- 
serous. 

It  is  in  the  ileo-csecal  region  that  intussuscep- 
tion most  frequently  occurs.  In  this  condition 
one  part  of  the  intestine  is  prolapsed  or  "  tele- 
scoped "  into  the  lumen  of  an  immediately  adjoin- 
ing part.  In  the  ileo-csecal  variety  (the  common- 
est form)  the  narrow  ileum,  and  subsequently  the 
caecum,  are  prolapsed  into  the  colon.  The  ileo- 
csecal  valve  forms  the  summit  of  the  protrusion 
or  intussusceptum.  By  a  gradual  increase  of 
the  condition  the  intussuscepted  bowel  may  at 
last  reach  the  rectum,  and  the  ileo-csecal  valve 
has,  in  fact,  been  recognised  protruding  from  the 
anus.  In  the  ileo-colic  variety  (the  rare  form) 
the  end  of  the  ileum  is  prolapsed  through  the 
valve.  The  valve  and  the  csecum  remain  in  their 
normal  situations,  and  the  summit  of  the  intus- 
susceptum is  formed  only  by  the  ileum.  In 
another  variety,  which  is  also  common,  the  apex 
of  the  intussusceptum  is  formed  by  the  fundus  of 
the  invaginated  csecum. 

There  are  three  fairly  constant  peritoneal 
fossae,  which  are  sometimes  the  seat  of  hernia,  in 
the  ileo-csecal  region  (Fig.  61).  They  are  (1)  the 
ileo-colic,  situated  between  the  ascending  colon 
and  termination  of  the  ileum;  a  fold  containing 
the  anterior  caecal  artery  bounds  it  above;  (2)  the 


Chap.  XVII]       ABDOMINAL   VISCERA  387 

ileo-csecal  fossa,  between  the  termination  of  the 
ileum  and  the  caecum;  it  is  bounded  in  front  by 
the  bloodless  fold  and  behind  by  the  mesentery 
of  the  appendix;  (3)  the  retrocecal  fossa,  behind 
the  caecum ;  it  is  bounded  on  the  right  by  the  lower 
termination  of  the  ascending  mesocolon. 

The  large  intestine.  —  From  the  caecum  tc 
the  sigmoid  flexure,  this  portion  of  the  bowel  is 
accessible  to  pressure  except  at  the  hepatic  and 
splenic  flexures,  which  are  deeply  placed.  The 
hepatic  flexure  is  under  the  shadow  of  the  liver, 
and  the  splenic  curve,  which  reaches  a  higher 
level,  is  behind  the  stomach  (Fig.  58,  p.  363).  The 
position  of  the  transverse  colon  can  often  be  well 
marked  out.  It  crosses  the  belly  transversely ,  so 
that  its  lower  border  is  nearly  on  a  level  with 
the  umbilicus  (Fig.  58).  In  cases  of  faecal  accu- 
mulation, the  outline  of  the  colon,  with  the 
exception  of  the  two  flexures  above  named,  may 
be  distinctly  defined.  In  distensions  of  the  small 
intestine  the  belly  tends  to  present  the  greatest 
degree  of  swelling  in  front,  and  about  and  below 
the  navel.  In  distension  of  the  larger  gut,  the 
front  of  the  abdomen  may  remain  (for  a  while  at 
least)  comparatively  flat,  while  the  distension  will 
be  most  obvious  in  the  two  flanks  and  in  the 
region  just  above  the  umbilicus.  Tumours  of  the 
transverse  colon,  and  of  the  lower  two-thirds  of 
the  ascending  and  descending  colon,  can  be  well 
defined,  even  when  of  moderate  size,  and  in  cases 
of  intussusception  the  progress  of  the  mass  along 
the  colon  can  often  be  traced  with  great  ease,  and 
the  effects  of  enemata  and  other  methods  of  re- 
duction carefully  watched.  The  diameter  of  the 
large  intestine  (excluding  the  rectum)  gradually 
diminishes  from  the  caecum  to  the  sigmoid  flexure, 
the  diameter  of  the  former  being  about  2^  inches, 
of  the  latter1  1^  inch.  The  narrowest  part  of  this 
segment  of  the  bowel  is  at  the  point  of  junction 
of  the  sigmoid  flexure  with  the  rectum,  and  it  is 
significant  that  it  is  at  this  point  that  stricture 
is  the  most  common. 


388  SURGICAL    APPLIED    ANATOMY       [Part  IV 

The  tendency  to  stricture  increases  as  one  pro- 
ceeds downwards  from  the  caecum  to  the  anus.  A 
stricture  is  frequent  in  the  descending  colon,  less 
frequent  in  the  transverse  colon,  while  in  the 
ascending  colon  it  is  comparatively  rare.  Stric- 
tures are  not  uncommon  about  the  flexures  of  the 
bowels.* 

The  ascending  and  the  descending  colon  are 
placed  vertically.  The  average  length  of  the  as- 
cending colon  in  the  adult  (as  measured  from  the 
tip  of  the  csecum  to  the  hepatic  flexure)  is  8  inches. 
The  average  length  of  the  descending  colon  (from 
the  splenic  bend  to  the  commencement  of  the  sig- 
moid flexure)  is  8^  inches.  The  descending  colon 
is  very  little  liable  to  variation,  and  is  always 
found  in  a  semi-contracted  condition.  That  part 
of  the  descending  colon  which  lies  in  the  left 
iliac  fossa,  from  the  iliac  crest  to  the  left  psoas 
muscle,  is  now  distinguished  as  the  iliac  colon. 
In  cases  of  non-descent  of  the  csecum  the  ascend- 
ing colon  may  be  absent  (p.  385).  I  have 
pointed  out  that  in  52  per  cent,  of  adult  bodies 
there  is  neither  an  ascending  nor  a  descending 
mesocolon,  and  that  a  mesocolon  may  be  expected 
on  the  left  side  in  36  per  cent,  of  all  cases,  and 
on  the  right  side  in  26  per  cent.  These  points 
are  of  importance  in  connection  with  the  some- 
what uncommon  operation  of  lumbar  colotomy. 
The  breadth  of  the  mesocolon,  when  it  exists, 
varies  from  1  to  3  inches.  The  line  of  attach- 
ment of  the  left  mesocolon  is  usually  along  the 
outer  border  of  the  kidney,  and  is  vertical.  That 
of  the  right  mesocolon  is,  as  a  rule,  less  vertical, 
runs  along  the  outer  border  of  the  kidney,  and 
crosses  its  lower  end  obliquely  from  right  to  left. 

The  transverse  colon  has  an  average  measure- 
ment of  20  inches.  It  is  not  quite  horizontal, 
since  the  splenic  flexure  is  on  a  higher  level  than 
the  hepatic  flexure,  as  well  as  posterior  to  it,  and 
always  shows  a  number  of  bends,  one  occurring 
near  its  commencement  and  another  near  its  end. 

*  See  "Intestinal  Obstruction."    By  the  Author.     London.     1899. 


Chap.  XVII]        ABDOMINAL    VISCERA  38«J 

Faecal  masses  lodged  in  the  transverse  colon  have 
given  rise  to  many  errors  in  diagnosis.  In  some 
instances  this  part  of  the  colon  is  displaced  to- 
wards the  pelvis,  so  that  V-  or  U-shaped  bends 
are  produced.  In  such  cases  the  point  of  the  V 
or  U  may  reach  the  symphysis  pubis,  while  the 
two  colic  flexures  occupy  their  proper  situations. 
These  deviations  are  described  in  detail  in  my 
work  on   Intestinal  Obstruction. 

The  right-hand  part  of  the  transverse  colon 
is  in  intimate  relation  with  the  gall-bladder,  and 
is  commonly  found  to  be  bile-stained  after  death. 
In  some  cases  where  gall  stones  have  been  lodged 
within  the  gall-bladder,  the  walls  of  that  struc- 
ture have  ulcerated  from  pressure,  the  ulceration 
has  involved  the  subjacent  transverse  colon,  and 
thus  a  fistula  has  been  established  between  the 
gall-bladder  and  the  gut,  through  which  large 
stones  have  been  passed.  Hepatic  abscesses  also 
have  discharged  themselves  through  the  trans- 
verse colon.  The  transverse  colon  often  finds  its 
way  into  an  umbilical  hernia,  and  has  been  found 
to  be  concerned  in  many  of  the  cases  of  hernia  into 
the  foramen  of  Winslow. 

The  sigmoid  flexure. — The  segments  of  gut 
termed  the  sigmoid  flexure  and  "  the  first  part  of 
the  rectum  ;;  form  together  a  single  simple  loop 
that  cannot  be  divided  into  parts.  This  loop  be- 
gins where  the  descending  colon  ends,  and  ends  at 
the  commencement  of  the  so-called  "  second  part 
of  the  rectum  ;; ;  at  a  spot,  in  fact,  where  the  meso- 
rectum  ceases,  opposite  about  the  third  piece  of 
the  sacrum.  This  loop,  when  unfolded,  describes 
a  figure  that,  if  it  must  be  compared  to  a  letter, 
resembles  the  capital  Omega.  It  may  well  be 
termed  the  Omega  loop,  and  the  term  rectum  be 
limited  to  the  short  piece  of  practically  straight 
gut  that  is  now  described  as  the  second  and  third 
parts  of  the  rectum.  By  the  majority  of  anato- 
mists and  surgeons  the  Omega  loop  is  now  named 
the  "  pelvic  colon,"  although  at  birth  and  fre- 
quently in  the  adult  it  is  not  pelvic  in  position. 


390  SURGICAL    APPLIED    ANATOMY       [Part  IV 

The  average  length  of  the  loop  in  the  adult  is 
1*7^  inches.  The  two  extremities  of  the  loop  are 
about  3  or  4  inches  apart.  If  they  are  approxi- 
mated to  one  another,  as  by  contracting  peri- 
tonitis at  the  root  of  the  sigmoid  mesocolon,  a 
kind  of  pedicle  is  established,  about  which  the 
loop  may  readily  become  twisted.  Such  a  twist 
of  the  bowel  constitutes  a  volvulus  of  the  sigmoid 
flexure;  and  it  may  be  here  said  that  volvulus 
of  the  intestine  is  more  commonly  met  with  in  this 
loop  than  in  any  other  part  of  the  canal. 

The  line  of  attachment  of  the  mesocolon  of  the 
Omega  loop  (the  sigmoid  mesocolon)  crosses  the 
left  psoas  muscle  and  the  iliac  vessels  near  their 
bifurcation ;  it  then  turns  abruptly  down,  and 
running  nearly  vertical,  terminates  at  the  middle 
line. 

In  the  left  wall  of  this  mesocolon,  close  to  the 
point  where  it  lies  over  the  iliac  vessels,  a  fossa 
is  sometimes  to  be  found.  It  is  produced  by  the 
sigmoid  artery,  and  is  about  l|  inch  in  depth. 
It  is  called  the  intersigmoid  fossa,  and  is  the 
seat  of  sigmoid  hernia  (Fig.  62,  mc).  Two  cases 
of  strangulated  hernia  in  this  fossa  have  been 
recorded. 

The  sigmoid  flexure,  or  Omega  loop,  when 
empty,  normally  occupies  the  pelvis.  When  dis- 
tended this  piece  of  bowel  may  become  so  enor- 
mously dilated  as  to  reach  the  liver.  The  chief 
examples  of  extraordinary  dilatation  of  the  colon 
concern  this  loop.  Faecal  masses  are  very  fre- 
quently lodged  in  the  free  end  of  the  loop,  and 
certain  intestinal  concretions  have  been  met  with 
in  the  same  situation. 

I  have  shown  by  experiment  that  the  "  long 
tube,"  when  introduced  through  the  anus,  cannot 
be  passed  beyond  the  sigmoid  flexure  in  ordinary 
cases,  and  with  a  normal  disposition  of  the  bowel. 

In  cases  of  congenital  absence  or  deficiency 
of  the  rectum,  the  sigmoid  flexure  is  often  opened 
in  the  groin  and  an  artificial  anus  established 
there.     This  operation,   known  as  Littre's  opera- 


Chap.  XVII]        ABDOMINAL   VISCERA 


391 


tion,  is,  it  must  be  confessed,  not  very  successful. 
One  difficulty  has  been  said  to  depend  upon  the 
uncertain  position  of  the  sigmoid  flexure  in  cases 
of  congenital  deformity,  it  being  sometimes  on  the 
right  side  and  sometimes  in  the  pelvis  at»  the 
middle  line.     It  is  rarely,  however,  found  in  these 


Pig.    62. — Sigmoid    flexure    turned   upwards    to  show  the   intersigmoid 
fossa.     (Jonnesco.) 

s  f,  Sigmoid  flexure  ;  a  s,  sigmoid  artery  ;  31  c,  mesosigmoid  fossa,  \~a  e,  external 
iliac  artery ;  r,  ureter  in  front  of  internal  iliac  vessels. 

positions.  _  Out  of  100  post-mortem  examinations 
on  young  infants,  Curling  found  the  loop  on  the 
left  side  in  eighty-five  cases.  Out  of  ten  children 
who  were  operated  on  for  imperforate  anus,  the 
loop  was  found  in  the  left  fossa  in  only  one  case 
(Montgomery). 

The  sigmoid  flexure   is  the   part  of  the  colon, 
opened  in  the  operation  of  left  iliac  or  inguinal 


392  SUEGICAL    APPLIED    ANATOMY     '  [Part  IS 

colotomy.  In  performing  this  operation  the 
length  of  the  sigmoid  mesocolon  and  the  conse- 
quent mobility  of  the  coil  are  of  much  importance. 
The  sigmoid  flexure,  when  empty  and  contracted, 
can  be  felt  through  the  parietes  in  moderately 
thin  subjects. 

Congenital  malformation  of  the  colon. — 
These  are  of  moment  with  regard  to  _  operative 
procedures.  It  may  be  very  briefly  said  that  in 
the  foetus  the  small  bowel  occupies  at  one  time 
the  right  side  of  the  abdomen,  while  the  large  gut 
is  represented  by  a  straight  tube  that  passes  on 
the  left  side  vertically  from  the  region  of  the 
umbilicus  to  the  pelvis.  The  caecum  is  at  first 
situated  within  the  umbilicus,  and  then  ascends  in 
the  abdomen  towards  the  left  hypochondrium.  It 
next  passes  transversely  to  the  right  hypochon- 
drium, and  then  descends  into  the  corresponding 
iliac  fossa.  It  may  be  permanently  arrested  at 
any  part  of  its  course.  Thus  the  caecum  may  be 
found  about  the  umbilicus,  or  in  a  congenital 
umbilical  hernia,  or  in  the  left  hypochondriac 
region  (the  ascending  and  transverse  parts  of  the 
colon  being  absent),  or  it  may.  be  found  in  the 
right  hypochondrium,  the  ascending  colon  only 
being  unrepresented. 

The  whole  of  the  large  intestine  has  at  one 
time  an  extensive  mesentery,  and  in  some  rare 
cases  this  condition  may  persist  throughout  life. 
When  it  does  persist,  it  may  lead  to  one  form  of 
volvulus  of  the  bowel. 

Lumbar  colotomy. — The  operation  so  named 
consists^  in  opening  the  colon  in  the  loin  behind 
the  peritoneum,  for  the  purpose  of  establishing 
an  artificial  anus.  The  operation  is  performed, 
when  possible,  #  upon  the  left  side,  in  preference 
to  the  right,  inasmuch  as  the  descending  colon 
ii  nearer  to  the  anus.  The  operation  has,  how- 
ever, been  almost  entirely  superseded  by  iliac 
colotomy  except  in  a  few  uncommon  conditions. 
The  position  of  the  descending  colon  in  the  loin 
may   be    represented   by    a   line    drawn   vertically 


Chap.  XVIIJ 


ABDOMINAL    VISCERA 


3&«? 


upwards  from  a  point  on  the  iliac  crest  1  inch 
external  to  the  outer  border  of  the  erector  spinse. 
An  incision  is  made  across  the  centre  of  this  line 
parallel  to  the  last  rib,  and   so  planned  that   the 


Fig.   63. — Horizontal    section    through    the    body   at  the   level    of   the 
umbilicus.     {After  Braune.) 

a,  Spine  of  the  fourth  lumbar  vertebra ;  b,  disc  between  third  and  fourth  verte- 
brae ;  c,  umbilicus  ;  d,  quadratus  lumborum  ;  e,  psoas  ;  /,  external  oblique,  with 
internal  oblique  and  transversalis  muscles  beyond ;  g,  rectus ;  'h,  descending 
colon ;  i,  transverse  colon  ;  j,  aorta  ;  Jc,  inferior  vena  cava  ;  I,  ureter. 

centre  of  the  incision  corresponds  to  the  centre  of 
the  line.  The  superficial  tissues  having  been  in- 
cised, the  following  structures  are  divided  in 
layers  in  the  following  order  (Fig.  63)  :  (1)  The 
latissimus  dorsi  and  external  oblique  muscles  to 
an  equal  extent ;   (2)  the  internal  oblique  in  the 


394  SURGICAL    APPLIED    ANATOMY  [Part  IV 

entire  length  of  the  incision ;  (3)  the  fascia  lum- 
borum, with  a  few  of  the  most  posterior  fibres, 
of  the  transversalis  muscle;  (4)  the  transversalis 
fascia.  The  quadratus  lumborum  will  be^  exposed 
in  the  posterior  inch  or  so  of  the  incision,  and 
usually  does  not  need  to  be  cut.  At  the  seat  of  the 
operation  the  descending  colon  occupies  the  angle 
between  the  psoas  and  quadratus  lumborum  mus- 
cles, and  the  non-peritoneal  surface  is  exactly  re- 
presented by  that  part  of  the  bowel  that  faces 
this  angle  (Fig.  63).  Thus,  if  during  the  opera- 
tion the  curved  finger  be  placed  in  this  angle,  and 
the  patient  be  rolled  over  to  the  left  side,  the 
bowel  that  falls  into  the  finger  cannot  well  be 
other  than  the  descending  colon.  The  gut  is 
drawn  forwards,  stitched  to  the  wound,  and 
opened  by  a  transverse  cut.  The  width  of  the 
non-peritoneal  surface  varies  from  fths  of  an  inch 
to  1  inch  in  the  empty  state,  and  may  attain  to 
2  inches  or  more  in  the  distended  condition 
(Braune). 

Iliac  or  iiagisiiial  colotomy. — In  this  very 
common,  excellent,  and  simple  operation  the  sig- 
moid flexure  is  exposed  and  opened  in  the  left 
iliac  region.  A  line  is  drawn*  from  the  anterior 
superior  iliac  spine  to  the  umbilicus,  and  an  in- 
cision some  2  inches  in  length  is  made  at  right 
angles  to  this  line  and  at  a  distance  of  about 
l|  inch  from  the  point  of  the  bone.  The  three 
muscles  of  the  abdomen  and  the  peritoneum  hav- 
ing been  divided,  the  loop  of  the  sigmoid  flexure 
is  Drought  into  the  wound,  is  secured,  and  is  (at 
once  or  at  a  later  period)  opened. 

The  caecum  may  be  opened  on  the  right  side, 
and  as  a  rule  the  most  convenient  incision  is  an 
oblique  one  placed  externally  to  the  deep  epigastric 
artery. 

Colectomy  consists  in  excising  a  portion  of 
the  colon.  The  caecum  has  been  removed,  and  con- 
siderable segments  of  the  rest  of  the  large  in- 
testine.^  The  m  treatment  of  cancer  of  the  colon 
by    excision    is    attended    with    considerable    sue- 


Chap.  XVII J       ABDOMINAL    VISCERA  395 

cess.  Portions  of  the  ascending  and  descending 
parts  of  the  colon  have  been  excised  through  an 
incision  in  the  loin,  but  colectomy  is  much  more 
readily  carried  out  through  an  anterior  wound. 
I  have  reported  a  case  in  a  young  girl,  in  which 
I  excised  the  whole  rectum  and  anus,  the  sig- 
moid flexure,  and  the  whole  of  the  descending 
colon.  The  divided  transverse  colon  was  brought 
out  at  the  anus.  The  child  made  a  perfect  re- 
covery. The  parts  removed  are  in  the  Museum  of 
the  Royal  College  of  Surgeons.  The  operation 
of  intestinal  anastomosis  or  short  circuiting  is 
very  frequently  practised  on  the  colon.  Thus,  in 
an  obstruction  on  the  descending  colon  incapable 
of  removal,  the  transverse  colon  may  be  united 
to  the  sigmoid  flexure. 

The  liver.  —  The  liver  is  moulded  to  the  arch 
of  the  diaphragm,  and  lies  over  a  part  of  the 
stomach  (Fig.  64).  Properly  speaking,  it  has  only 
two  surfaces — a  visceral  surface,  which  in  the 
upright  posture  rests  on  the  stomach,  duodenum, 
gastro-hepatic  omentum,  neck  of  the  pancreas, 
hepatic  flexure  of  colon,  right  kidney,  and  right 
suprarenal  bodv;  and  a  parietal  surface,  in  con- 
tact with  the  diaphragm  and  anterior  belly  wall 
in  the  subcostal  angle.  As  seen  from  the  front  it 
is  triangular  in  outline,  with  its  apex  near  the 
apex  of  the  heart  (Fig.  64);  its  upper  border  is 
best  indicated  by  a  line  commencing  at  the  apex 
beat  (Fig.  64)  and  passing  across  the  mid  line 
\  an  inch  below  the  sterno-ensiform  point :  it 
ascends  as  it  reaches  the  nipple  line  to  the  level  of 
the  sterno-ensiform  plane.  The  lower  border  com- 
mences at  the  apex  beat,  crosses  the  mid  line  about 
1  inch  above  the  mid-epigastric  point,  reaches 
the  costal  margin  at  the  outer  border  of  the 
rectus,  and  the  remainder  of  its  lower  border 
corresponds  to  the  costal  margin  as  far  as  the  tip 
of  the  eleventh  rib.  The  liver  is  in  contact  with 
the  right  kidney  along  the  lower  margin  of  that 
rib  (Fig.  68).  For  surgical  purposes  the  liver  in 
the    right    hypochondrium    may    be    regarded    as 


396 


SUEGICAL    APPLIED    ANATOMY      [Part  IV 


made  up  of  three  zones — an  upper  or  pulmonary, 
a  middle  or  pleural,  and  a  lower  or  diaphrag- 
matic (Fig.  64).  In  the  lower  zone,  which  is  1|  to 
2  inches  wide  in  the  mid-axillary  line,  the  liver 
may  be  incised  or  explored ;  in  the  middle  zone, 
which  is  of  equal  width,  the  pleural  reflection  is 
encountered.  In  the  erect  posture  the  lower  edge 
on  the  right  side  is  about  \  or  \  of  an  inch  below 


STEB/lO-EflSIF.  LlAE 

Apex  Poi/it 

Pulmonary  Lime 

Pleural  Line 

/Iepatic  Duct 

Cystic  Duct 

Pancreas 

Duodenum 

Alio  Epiqastric  Line 

Pylorus 

Stomach 

COMMON6lLEDUCT 
DUODENUM 


* ^  Linea  Alba 

<*•  " 

>  Umbilical  Line 

i 

lLlNEA5ENILUNARI5 


Fig.  64. — Diagram  showing  the  position  of  the  liver,  gall-bladder,  bile- 
ducts,  and  pancreas. 
The  lower  limits'of  the  pleura  and  lung  are  indicated. 

the  margins  of  the  costal  cartilages.  In  the  re- 
cumbent position  the  liver  ascends  about  an  inch, 
and  is  entirely  covered  by  the  costse,  except  at  the 
subcostal  angle.  It  descends  also  in  inspiration 
and  rises  in  expiration. 

The  fundus  of  the  gall-bladder  approaches  the 
surface  behind  the  ninth  costal  cartilage,  close  to 
the  outer  border  of  the  right  rectus  muscle  (Fig. 
64).  Its  position  is  extremely  variable ;  it  fre- 
quently occupies  a  position  considerably  below 
and  external  to  the  one  mentioned. 


Chap.  XVII]        ABDOMINAL   VISCERA  397 

The  liver  is  retained  in  shape  by,  and  moulded 
upon,  the  diaphragm  above  and  the  abdominal 
organs  below.  When  removed  from  the  body  the 
shape  is  lost  which  it  possesses  clinically.  It  pre- 
sents many  variations  in  form.  One  of  the  com- 
monest is  a  linguiform  process,  usually  known 
as  UiedeVs  lobe,  which  projects  from  the  margin 
of  the  right  lobe  under  the  tenth  costal  cartilage 
(Fig.  59,  p.  365).  It  is  found  more  frequently  in 
women  than  in  men,  and  may  be  mistaken  for  a 
floating  kidney  or  an  abdominal  tumour. 

In  the  condition  know  as  ptosis  of  the  liver  the 
organ  slides  from  the  dome  of  the  diaphragm, 
and  may  descend  to  the  level  of  the  umbilicus  or 
reach  the  iliac  fossa  (Fig.  59).  With  the  descent 
there  is  also  a  rotation  on  its  transverse  axis,  so 
that  its  diaphragmatic  surface  comes  almost  com- 
pletely to  the  front.  In  such  a  case  the  factors 
which  maintain  the  liver  in  position  have  to  be 
considered.  They  are  :  (l)  its  fixation  to  the 
diaphragm  by  the  inferior  vena  cava  and  the 
fibrous  tissue  on  the  non-peritoneal  posterior  sur- 
face of  the  right  lobe  in  the  neighbourhood  of 
the  inferior  vena  cava.  (2)  The  peritoneal  folds, 
which  include  the  right  and  left  lateral,  coronary, 
and  falciform  ligament,  also  attach  it  to  the  dia- 
phragm. These  folds  are  lax,  in  order  to  allow 
the  free  movements  of  the  liver  which  occur  during 
respiration  and  in  filling  and  emptying  of  the 
stomach.  (3)  The  muscular  abdominal  walls. 
These  keep  the  other  abdominal  viscera  constantly 
pressed  against  the  lower  surface  of  the  liver. 
The  muscles  constitute  the  chief  means  for  main- 
taining the  liver  in  position.  In  many  women 
over  forty  the  right  lobe  of  the  liver  projects 
quite  2  inches  below  the  eleventh  rib,  and  as  in 
the  child,  the  extremity  of  the  left  lobe  frequently 
comes  in  contact  with,  or  even  overlaps,  the  upper 
part  of  the  spleen. 

The  liver  is  more  often  ruptured  from  con- 
tusion than  is  anv  other  abdominal  viscus.  This 
is  explained  by  its  large  size,   its  comparatively 


398  SURGICAL   APPLIED    ANATOMY       [Part  IV 

fixed  position,  its  great  friability  of  structure, 
and  the  large  quantity  of  blood  contained  in  its 
vessels.  A  normal  liver  will  take  its  own  weight 
of  blood  if  its  veins  be  injected  at  ventricular 
pressure  (Salaman).  Death  in  such  injuries 
usually  ensues  from  haemorrhage,  since  the  walls 
of  the  portal  and  hepatic  veins,  being  incorpo- 
rated with  the  liver  substance,  are  unable  to  re- 
tract or  to  collapse.  The  hepatic  veins  also  open 
direct  into  the  vena  cava,  and,  being  unprovided 
with  valves,  could  allow  of  the  escape  of  an  im- 
mense quantity  of  blood,  if  any  retrograde  cur- 
rent were  established.  The  hepatic  vessels  are 
thin-walled,  and  it  is  almost  impossible  to  liga- 
ture them,  except  by  buried  sutures.  It  is  possi- 
ble for  the  liver  to  be  ruptured  without  the 
peritoneal  coat  being  damaged.  Such  injuries 
may  be  readily  recovered  from.  The  liver  pre 
sents,  behind,  a  fairly  extensive  non-peritoneal 
surface,  at  which  rupture  or  wound  may  occur 
without  extravasation  into  the  abdominal  cavity. 
From  the  relation  of  the  liver  to  the  right  lower 
ribs,  it  follows  that  this  viscus  may  be  damaged 
when  the  ribs  are  fractured,  and  in  some  cases 
the  broken  ends  of  the  bones  have  been  driven 
through  the  diaphragm  into  the  liver  substance. 
Stabs  through  the  sixth  or  seventh  right  inter- 
costal space,  over  the  liver  region,  would  wound 
both  the  lung  and  the  liver,  would  involve  the 
diaphragm,  and  open  up  both  the  pleural  and 
peritoneal  cavities. 

The  intimate  relation  of  the  liver  to  the 
transverse  colon  is  illustrated  by  a  case  where 
a  toothpick,  4  inches  in  length,  was  found  in 
the  substance  of  the  liver.  It  had  worked 
its  way  there,  from  the  colon,  along  an  abscess 
cavity  that  connected  the  two  viscera.  The 
relation  of  the  liver  to  the  heart  may  be  illus- 
trated by  a  case  still  more  remarkable.  In  this 
instance  a  loose  piece  of  liver,  weighing  1 
drachm,  was  found  in  the  pulmonary  artery.  The 
patient  had  been  crushed  between  two  waggons, 


Chap.  XVII         ABDOMINAL   VISCEEA  399 

the  liver  was  ruptured,  and  the  diaphragm  torn. 
A  piece  of  the  liver  had  been  squeezed  along  the 
vena  cava  into  the  right  auricle,  whence  it  had 
passed  into  the  right  ventricle,  and  so  into  the 
pulmonary  artery.  The  heart  itself  was  quite 
uninjured.  Portions  of  the  liver  may  protrude 
through  abdominal  wounds,  and  are  usually  easy 
to  reduce.  In  one  instance  of  such  protrusion  the 
surgeon  did  not  find  the  reduction  easy,  so  he 
placed  a  ligature  round  the  projecting  part  of 
the  viscus,  and  then  cut  this  obstinate  portion 
of  the  liver  off.  The  patient  recovered.  Con- 
siderable portions  of  the  liver  have  been  removed 
with  success.  It  is  remarkable  from  what  grave 
injuries  of  the  liver  recovery  is  possible.  Thus,  Dr. 
Gann  (Lancet,  June,  1894)  reports  the  case  of  a 
man  of  28,  who  had  a  harpoon  driven  through  the 
whole  thickness  of  the  right  lobe  of  the  liver,  so 
that  it  projected  at  the  posterior  border.  The 
blade  was  7  inches  long,  and  had  two  barbs.  It 
was  removed  by  operation  twenty-eight  hours 
after  the  accident,  and  the  patient  made  a  good 
recovery. 

f/roni  a  reference  to  the  relations  of  the  liver, 
it  will  be  readily  understood  that  an  hepatic  ab- 
scess may  open  into  the  pleura,  and  in  some  cases, 
indeed,  the  pus  from  the  liver  has  been  discharged 
from  the  bronchi.  Thus,  it  has  been  possible  for  a 
patient  to  cough  up  some  portion  of  his  liver, 
although,  of  course,  in  a  very  disintegrated  and 
minute  form.  Hepatic  abscess  may  burst  in  one 
or  other  of  the  following  directions,  placed  in 
order  of  their  frequency  :  (1)  into  the  right  lung; 
(2)  into  the  bowel;  (3)  upon  the  surface  of  the 
body.  Such  abscesses  have,  in  rare  cases,  opened 
into  the  stomach.  The  liver  is  very  frequently 
the  seat  of  the  secondary  abscess  of  pyaemia,  and, 
according  to  Mr.  Bryant's  statistics,  abscesses  in 
this  viscus  are  more  common  after  injuries  to  the 
head  than  after  injuries  elsewhere.  They  are 
rare  in  pyaemia  following  affections  of  the  urinary 
organs,  and  are  equally  rare  in  the  pyaemia  after 


400  SURGICAL    APPLIED    ANATOMY        [Part  IV 

burns.  Secondary  deposits  of  tumours  and  ab- 
scesses are  frequently  limited  to  the  right  or  to 
the  left  of  a  line  drawn  from  the  fundus  of  the 
gall-bladder  to  the  inferior  vena  cava.  This  re- 
markable limitation  is  to  be  explained  by  the  fact 
that  the  liver  to  the  right  of  this  line  is  supplied 
only  by  the  right  terminal  division  of  the  portal 
vein,  while  the  part  to  the  left  receives  blood  only 
from  the  left  division  (Cantlie). 

The  gall-bladder  may  be  absent,  as  is  the 
case  with  some  animals,  or  reduced  to  a  cica- 
trix from  disease.  Its  mucous  membrane  has  a 
peculiar  reticulated,  honeycomb  appearance.  It  is 
often  occupied  by  gall  stones.  These  concretions 
are  composed  mostly  of  cholesterin,  a  normal  con- 
stituent of  bile,  and  vary  in  size  from  a  hemp 
seed  to  a  hen's  egg.  The  escape  of  gall  stones 
is  rendered  more  difficult  by  the  presence  of 
a  spiral  fold  of  mucous  membrane  in  the  neck  and 
duct  of  the  gall-bladder.  The  gall-bladder,  at  its 
neck,  forms  an  acute  angle  with  the  cystic  duct, 
the  spinal  fold  being  necessary  to  keep  the  passage 
open.  In  the  erect  position  the  long  axis  of  the 
gall-bladder  is  directed  upwards  and  backwards, 
and  the  cystic  duct  downwards  and  forwards 
(Fig.  64).  The  cystic  duct  lies  in  the  gastro- 
hepatic  omentum,  where  it  joins  the  hepatic  to 
form  the  common  bile-duct.  It  is  accompanied  by 
the  cystic  artery.  The  cystic  veins  pass  directly 
into  the  liver  and  end  in  the  portal  capillary  sys- 
tem. In  cases  of  cystitis  the  part  of  the  liver 
receiving  the  cystic  veins  is  seen  to  be  contracted 
or  atrophied. 

A  gall  stone  may  be  arrested  in,  and  require 
removal  from,  any  part  of  the  cystic  or  common 
bile-ducts.  The  common  bile-duct  is  3  inches  long, 
and  its  lumen  ith  of  an  inch  wide,  but  by  the  pas- 
sage of  the  gall  stones  it  may  become  three  times 
its  normal  diameter.  The  upper  half  of  the  com- 
mon bile-duct  lies  in  the  gastro-hepatic  omentum, 
in  front  of  the  foramen  of  Winslow,  with  the 
portal    vein   behind    it    and    to    the    right.      The 


Chap.  XVII]        ABDOMINAL    VISCERA  401 

hepatic  artery  lies  close  to  it  on  the  left,  and  its 
branch,  the  superior  pancreatico-duodenal,  crosses 
the  common  bile-duct  as  it  passes  to  its  second 
or  deeper  stage.  '  A  stone  arrested  in  the  lower 
half  of  the  duct  is  difficult  of  access.  The  duct 
lies  buried  between  the  head  of  the  pancreas  be- 
hind and  the  duodenum  in  front  and  to  the  outer 
side.  It  may  be  necessary  in  such  a  case  to  open 
the  duodenum  and  extract  the  stone  through  its 
posterior  and  inner  wall,  or  the  duodenum  and 
head  of  the  pancreas  may  be  turned  forwards  from 
the  inner  border  of  the  right  kidney,  thus  expos- 
ing the  lower  half  (post-duodenal,  stage)  of  the 
common  bile-duct  in  the  groove  between  the  duo- 
denum and  pancreas.  The  terminal  half-inch  is 
embedded  in  the  wall  of  the  duodenum  and  ends 
in  the  ampulla  of  Vater.  At  its  termination  it  is 
surrounded  by  a  sphincter  which  regulates  the 
flow  of  bile.  The  lumen  of  the  lower  half  of  the 
duct  is  less  than  that  of  the  upper  half.  Two 
lymphatic  glands  lie  in  the  gastro-hepatic  omen- 
tum by  the  side  of  the  bile-duct,  and  have  been 
mistaken  for  gall  stones  when  calcified. 

The  gall-bladder  receives  its  nerve  supply  from 
the  eighth  and  ninth  segments  of  the  cord  (Head) 
through  the  great  splanchnic  and  cceliac  plexus. 
The  intense  colic  caused  by  gall  stones,  believed 
to  be  due  to  spasm  of  the  non-striated  muscular 
coat  of  the  bile-ducts,  is  reflected  along  the  ninth 
dorsal  nerve  to  the  anterior  abdominal  wall. 
Stimulation  of  the  sympathetic  nerves  causes  the 
muscle  of  the  cystic  duct  to  contract,  but  relaxes 
that  of  the  gall-bladder  (T.  R.  Elliot). 

The  gall-bladder  and  the  bile-duct  have  been 
ruptured  alone  without  rupture  of  the  liver.  The 
injury  is  rapidly  fatal,  owing  to  the  escape  of  bile 
into  the  peritoneal  cavity.  Large  gall  stones  may 
be  passed  direct  into  the  bowel  through  a  fistulous 
tract  that  has  been  established  between  the  gall- 
bladder and  the  intestine.  Gall  stones  have  sup- 
purated out  through  the  anterior  belly  wall,  and 
have  been  removed  from  abscesses  in  the  parietes. 
2  a 


402 


SUEGICAL   APPLIED    ANATOMY    [Part  IV 


Thus  Dr.  Burney  Yeo  reports  a  case  where  more 
than  one  hundred  gall  stones  were  discharged 
through  a  spontaneous  fistula  in  the  hypogastric 
region,  5  inches  below  the  umbilicus.  In  cases 
where  the  bile-duct  is  occluded  by  gall  stones,  or 
by  other  causes,  the  gall-bladder  may  become 
enormously   distended,    and  may   form  a  tumour 


l/iFE-atOR  Vena  Cava 
■Stermi-Bisiform  Li/ie- 

FUNDUS  OFSTOMACfl 

Liver 
Oesophageal  Orifice 

5PLEE/1 

Pulmonary  l\ne 
Riq/it  Suprarenal 

fllD-EPICASTR.IC  LlflE 
Pl_E  URAL   LI/SE 

Pelvis  of  Kidney 
R-iq/jT  Kid/hey 
Erector  Spimae 

Asce/idinc  Colon 

quadratus  lumboeum 
Umbilical  Line 
Ureter 

Post.  5up  Iliac  5pm& 


Fig.  65. — The  position  and  relationships  of  the  abdominal  viscera  from 

behind. 

The  lower  limits  of  the  pleura  and  lung  are  shown  in  red. 

extending  some  way  beyond  the  umbilicus.  So 
large  a  tumour  has  been  formed  that  the  mass  has 
been  mistaken  for  an  ovarian  cyst.  The  gall- 
bladder as  it  enlarges  tends  to  follow  a  line 
extending  from  the  tip  of  the  right  tenth  car- 
tilage across  the  median  line  of  the  abdomen  below 
the  umbilicus.  For  the  relief  of  this  condition, 
cholecystotomy,  or  incision  into  the  gall-bladder, 
has   been   performed.     In   this   operation   the   in- 


Chap.  XVII]        ABDOMINAL    VISCERA 


403 


cision  or  puncture  is  made  over  the  most  promi- 
nent part  of  the  tumour.  Impacted  gall  stones 
have  been  removed  entire  from  the  bile-duct 
through  an  incision  so  made,  or  the  stone  has  been 
crushed  in  situ  and  extracted  in  fragments. 

In  cholecystectomy  the  whole  of  the  gall-blad- 
der is  excised  and  the  cystic  duct  closed.  The  bile 
finds  its  way  into  the  intestine  direct  through  the 
common  duct. 

o        f, 
h        ^-^        i  ST 


Fig.  66. — Horizontal  section  through  upper  part  of  abdomen.    {Rudinger.) 


a,  Liver;   h,  stomach;   c,  transverse  colon;  d,  spleen;   e,  kidneys;  /,  pancreas 
<j,  inferior  vena  cava ;  h,  aorta  with  thoracic  duct  behind  it. 

In  cholecyst enter ostomy  a  fistula  is  established 
between  the  gall-bladder  and  the  intestine.  The 
operation  is  carried  out  in  cases  in  which  there 
is  an  insuperable  obstruction  in  the  common  duct. 
The  gall-badder  thus  takes  the  place  of  the  com- 
mon duct. 

The  spleen. — The  spleen  is  deeply  situated  in 
the  left  hypochondriac  region,  and  in  the  normal 
condition  cannot  be  palpated,  being  quite  covered 
in  front  by  the  cardiac  end  of  the  stomach  (Fig. 
65).  It  most  closely  approaches  the  surface  in 
the  parts  covered  by  the  tenth  and  eleventh  ribs. 


401  SURGICAL   APPLIED   ANATOMY    [Part  IV 

Above  this  it  is  entirely  overlapped  by  the  edge 
of  the  lung.  It  is  in  all  parts  separated  from 
the  parietes  by  the  diaphragm.  "  It  lies  very 
obliquely,  its  long  axis  coinciding  almost  exactly 
with  the  line  of  the  tenth  rib.  Its  highest  and 
lowest  points  are  on  a  level,  respectively,  _  with  the 
ninth  dorsal  and  first  lumbar  spines;  its  inner 
end  is  distant  about  1^  inch  from  the  median 
plane  of  the  body,  and  its  outer  end  about  reaches 
the  mid-axillary  line  ;;  (Quain)  _  (Fig.  65).  It 
possesses  three  surfaces,  gastric,  renal,  and 
phrenic,  well  shown  in  Fig.  66. 

A  dislocated  or  floating  condition  of  the  spleen 
is  rare.  Its  renal  surface  is  fixed  firmly  to  the 
upper  half  of  the  left  kidney ;  its  gastric  surface 
is  kept  in  apposition  to  the  stomach  by  the  gastro- 
splenic  omentum ;  its  upper  pole  is  attached  near 
the  cardiac  orifice  of  the  stomach  by  a  suspen- 
sory fold  of  peritoneum,  while  its  lower  rests  on 
the  costo-colic  peritoneal  fold,  and  has  the  tail  of 
the  pancreas  and  colon  in  contact  with  it.  The 
tension  of  the  abdominal  walls  exerts  a  general 
pressure  on  it  through  the  other  abdominal 
organs.  When  the  spleen  enlarges,  as  in  ague,  its 
crenated  anterior  border  may  be  felt  beneath  the 
tenth  costal  cartilage.  The  movable  or  floating 
spleen  is  met  with  only  in  adults.  >  The  organ  may 
be  so  displaced  as  to  reach  the  iliac  fossa. 

Injuries. — Although  extremely  friable  in  struc- 
ture, the  normal  spleen  is  not  very  frequently 
ruptured.  Its  connections,  indeed,  tend  to  mini- 
mise the  effects  of  concussions  and  contusions. 
When  the  spleen,  however,  is  enlarged,  it  is  very 
readily  ruptured,  and  often  by  quite  insignifi- 
cant violence.  Thus,  several  cases  have  been  re- 
corded of  rupture  of  an  enlarged  spleen  by  mus- 
cular violence.  For  instance,  a  woman  ruptured 
her  spleen  in  an  attempt  to  save  herself  from  fall- 
ing, and  another  in  springing  aside  to  avoid  a 
blow.  The  patients  in  each  instance  were  natives 
of  India,  and  the  latter  case  gave  rise  to  a  charge 
of    homicide.     The    spleen    being    extremely    vas- 


Chap.  XVII]  ABDOMINAL    VISCERA  405 

cular,  it  follows  that  ruptures  of  the  viscus  are 
usually,  but  not  necessarily,  fatal  from  haemor- 
rhage. It  is  well  to  note,  in  connection  with  this 
matter,  that  the  spleen  contains  most  blood  during 
digestion.  A  case  is  reported,  however,  of  a  boy 
who  met  with  an  accident  just  after  dinner,  and 
who  managed  to  walk  some  distance,  although  his 
spleen,  as  the  autopsy  revealed,  was  separated  into 
three  portions.  He  lived  some  days.  In  severe 
fractures  of  the  ninth,  tenth,  and  eleventh  ribs 
the  spleen  may  be  damaged  and  lacerated. 

The  capsule  of  the  spleen  contains  muscular 
tissue,  and  must  possess  some  contractile  power. 
This  fact  may  serve  to  explain  cases  of  recovery 
from  limited  wounds  of  the  organ,  such  as  small 
gunshot  wounds.  In  such  lesions  the  capsule  may 
contract  and  greatly  narrow  the  hole  in  the  viscus, 
while  the  track  of  the  bullet  or  knife  may  become 
filled  with  blood-clot,  and  the  bleeding  thus  be 
stayed. 

The  spleen  may  be  greatly  enlarged  in  certain 
diseased  conditions.  The  hypertrophied  spleen 
may  attain  such  dimensions  as  to  fill  nearly  the 
whole  abdomen,  and  in  one  case  a  cystic  tumour  so 
completely  occupied  both  iliac  fossae  that  it  was 
mistaken  for  an  ovarian  cyst,  and  the  operation 
for    ovariotomy    was   commenced. 

Extirpation  of  the  spleen  has  been  suc- 
cessful in  cases  of  abdominal  wounds  with  pro- 
trusion of  the  viscus.  It  has  also  been  performed 
with  fair  results  in  many  cases  of  hypertrophied 
spleen,  and  of  wandering  spleen.  The  operation 
is  not  justifiable  in  cases  of  leukaemic  enlargement 
of  the  organ,  it  having  proved  invariably  fatal 
in  such,  instances.  In  cases  of  wounds  with  pro- 
trusion, the  spleen  is,  of  course,  removed  through 
the  wound.  In  other  instances  the  incision  is 
usually  made  in  the  middle  line,  the  most  con- 
venient being  one  so  arranged  that  the  umbilicus 
corresponds  to  the  centre  of  the  cut.  Some  sur- 
geons prefer  an  incision  along  the  outer  edge  of 
the  left  rectus  muscle.     The  viscus  is  then  slowly 


406  SUEGICAL   APPLIED    ANATOMY    [Part  IV 

pressed  out  of  the  wound.  The  great  difficulty 
is  with  the  gastro-splenic  omentum,  which  has 
to  be  divided  and  its  vessels  secured.  In  drawing 
out  the  spleen  there  is  much  risk  of  tearing  the 
splenic  vessels,  especially  the  vein.  Special  care 
has  to  be  taken  to  avoid  damage  to  the  pancreas. 
The  splenic  artery,  with  its  large  accompanying 
vein,  lies  in  the  lieno-renal  ligament,  in  contact 
with  the  tail  of  the  pancreas  below. 

The  pancreas  lies  behind  the  stomach,  in 
front  of  the  first  and  second  lumbar  vertebrae 
(Fig.  64).  It  crosses  the  middle  line  behind  the 
mid-epigastric  line  (Fig.  64).  In  emaciated  sub- 
jects, and  when  the  stomach  and  colon  are  empty, 
it  may  sometimes  be  felt  on  deep  pressure,  espe- 
cially in  those  who  are  the  subjects  of  visceroptosis ; 
prolapse  of  the  stomach  leaves  the  pancreas  ex- 
posed above  the  lesser  curvature.  It  is  in  relation 
with  many  most  important  structures.  So  closely 
is  it  mixed  up  with  the  solar  plexus  that  this 
structure  is  necessarily  involved  in  any  operative 
procedures  on  its  head  and  neck.  It  has,  I  be- 
lieve, never  been  ruptured  alone,  and  it  could 
scarcely  be  wounded  without  the  wound  implicat- 
ing other  and  more  important  viscera.  It  has 
been  found  herniated  in  some  very  rare  cases  of 
diaphragmatic  hernia,  but  never  alone.  The  main 
duct  (duct  of  Wirsung)  usually  terminates  with 
the  common  bile-duct  in  the  ampulla  of  Vater 
(Fig.  67,  a),  so  that  a  gall  stone  arrested  at  this 
point  may  occlude  both  ducts  or  possibly  cause 
a  reflux  of  the  bile  within  the  pancreatic  duct. 
Not  uncommonly  (in  30  per  cent,  of  cases)  the 
ampulla  is  partly  (Fig.  67,  b)  or  completely 
divided  (Fig.  67,  c),  so  that  the  orifices  of  the  two 
ducts  are  separated ;  in  such  cases  occlusion  of 
the  termination  of  the  bile  passage  leaves  the  pan- 
creatic duct  free.  A  secondary  duct  (the  duct 
of  Santorini)  is  present  in  a  more  or  less  de- 
veloped condition  in  50  per  cent,  of  subjects.  It 
may  form  a  connection  with  the  main  duct,  as  in 
Fig.  67,  a,  or  be  merely  a  minute  ductule,  as  in 


Chap.  XVII]  ABDOMINAL    VISCERA 


407 


Fig.  67,  b.  The  accessory  duct  opens  nearer  the 
pylorus,  being  f  of  an  inch  above  the  ampulla 
of  Vater.  The  ampulla  _  usually  extends  into  a 
papilla  which  projects  within  the  duodenum,  but 
this  papillated  condition  is  not  always  present. 
Septic  conditions  may  spread  from  the  duodenum 
to  the  pancreas  or  gall-bladder  by  means  of  their 
ducts. 

The  common  bile-duct  in  its  second  stage  lies 
between  the  head  of  the   pancreas   and  the   duo- 


Fig.  67. — Diagrams  to  show  the  variations  in  the  manner  of  termination 
of  the  pancreatic  and  bile  ducts. 

A,  Form  in  which  the  common  bile-cluctl(c,  b,  n)  and  main  pancreatic  duct  (b) 
end  in  an  ampulla  (e).  a.  Duct  of  Santorini;  i.,  ii.,  iii,  first,  second,  and  third 
stages  of  the  duodenum. 

B,  Form  in  which  the  ampulla  is  partly  divided.    The  duct  of  Santorini  is  shown 

in  its  reduced  form. 

C,  Form  in  which  the  common  bile-duct  and  pancreatic  duct  have  separate 

openings  into  the  duodenum.    The  duct  of  Santorini  is  absent. 

denum.  It  thus  happens  that  in  carcinoma  of 
this  part  of  the  gland  the  duct  may  become  en- 
tirely occluded  and  jaundice  result.  Or  the  duo- 
denum and  even  the  colon  may  be  more  or  less 
obstructed  by  pressure,  or  the  neighbouring 
vessels  be  closed.  Cancer  of  the  pylorus  may 
spread  to  the  head  of  the  pancreas  by  direct 
extension.  The  lymphatics  of  the  two  parts  also 
freely  communicate. 

The  pancreas  lies  behind  the  lesser  sac  of  the 
peritoneum,  its  anterior  surface  being  covered  by 
the  posterior  wall  of  the  sac.  It  lies  in  front  of 
the    aorta,    in  the   fork   between   the    coeliac    axis 


408  SURGICAL    APPLIED    ANATOMY    [Part  IV 

above  and  the  superior  mesenteric  artery  below. 
The  portal  vein  passes  upwards  behind  the  neck 
of  the  gland. 

Certain  remarkable  cysts  are  sometimes  de- 
veloped in  the  pancreas.  They  may  attain  great 
size  and  nearly  fill  the  abdomen. 

The  kidney. — Its  relations  are  as  follows  : — 

In  front. 

Right.  Left. 

Visceral  surface  of  liver.  Fundus  of  stomach. 

Second  part  of  duodenum.  Descending  colon. 

Commencement  of  transverse  colon.  Pancreas. 

Ascending  colon.  Spleen. 


Externally. 
Liver. 


Kidney. 


Externally. 
Spleen. 


Behind. 


Lower  part  of  arch  of  diaphragm. 

Quadratus  lumborum.    Psoas.    Transversalis. 

Last  rib  and  transverse  proeesses  of  upper  two  lumbar  vertebra. 

The  kidneys  are  deeply  placed,  and  cannot  be 
felt  or  distinctly  identified  when  normal.  They 
are  most  accessible  to  pressure  at  the  outer  edge 
of  the  erector  spinse,  just  below  the  last  rib  (Figs. 
65  and  68).  The  dulness  of  the  right  kidney 
merges  above  in  that  of  the  liver,  while  on  the  left 
side  it  is  impossible  to  distinguish  between  the 
dulness  of  the  kidney  and  spleen.  The  right  kid- 
ney lies  usually  lower  down  than  does  the  left ;  but 
even  the  lower  pole  of  the  right  kidney  is  an 
inch  above  the  crest  of  the  ilium — or  what  for 
practical  purposes  is  the  same  level — above  the 
umbilical  line  (Fig.  58,  p.  363).  The  simplest 
manner  of  indicating  the  position  of  a  kidney  is 
to  mark  out  the  position  of  the  upper  and  lower 
pole  and  between  those  two  points  mark  on  the 
well-known  form  of  the  kidney.  The  lower  pole 
of  the  right  organ  lies  about  \  an  inch  outside 
the  prominent  lateral  border  of  the  erector  spinse 
and  1  inch  above  the  iliac  crest  (Fig.  65) ;  since 
the  kidney  is  about  4  inches  long  and  is  situated 
obliquely — its  long  axis  corresponding  to  that  of 
the  twelfth  rib — its  upper  pole  is  sufficiently  in- 


Chai).  XVII  I 


ABDOMINAL    VISCERA 


409 


clicated,  by  taking  a  point  4  inches  above  and 
lh  inch  internal  to  the  position  of  the  lower  pole. 
The  spine  of  the  eleventh  dorsal  vertebra — which 
may  be  identified  when  the  patient  bends  by  its 


fAV\\^  a>'\. ■♦t-^\V 


fit 


Fig.  68. — Showing   the    relationships  of  the   kidney   and   colon   in    the 
lumbar  region  from  behind.     (Adapted  from  Merkel.)  * 

p.l.,  Lower  line  of  pleura ;  xi.,  eleventh  rib ;  xil,  twelfth  rib ;  12th  d.n.,  twelfth 
dorsal  nerve  ;  1st  l.n.,,  ilioinguinal and  ilio-hypogastric  nerves;  a.b.,  vertical 
line  representing  position  of  descending  colon  (desc.  c.) ;  q.l.,  quadratus  lum- 
borum ;  e.s.,  erector  spinas ;  peritoneum  (perit.)  is  shown  reflected  from  the 
front  of  the  kidney  to  the  colon  on  the  right  side. 

anti-clinal  direction  and  semilumbar  form — is 
just  below  the  level  of  the  upper  pole.  On  an 
average  the  left  kidney  lies  \  an  inch  higher  than 
the  right   (Addison).     In  many   instances   in  the 

*  The  kidneys  are  represented  in  the  position  they  assume  when  the 
body  is  turned  on  its  face  ;  in  the  supine  position  they  fall  inwards  and 
backwards  into  the  position  described  in  the  text.  In  the  subject 
figured  above,  the  12th  rib  is  shorter  than  is  common. 


410  SURGICAL   APPLIED    ANATOMY    [Part  IV 

female  its  lower  end  reaches  the  iliac  crest,  and 
may  even  go  below  it.  Such  positions  are  much 
less  common  in  the  male.  The  hilum  lies  about 
2  inches  from  the  middle  line,  and  is  opposite  to 
the  first  lumbar  spine  and  usually  in  the  gap 
between  the  transverse  processes  of  the  first  and 
second  lumbar  vertebrae  (Fig.  65,  p.  402).  In 
radiograms  of  the  injected  ureter,  the  shadow  of 
the  pelvis  of  the  kidney  is  seen  to  fall  across  those 
of  the  transverse  processes  just  mentioned,  and 
also  that  of  the  last  rib  (Fig.  70,  p.  418). 

The  anterior  surface  is  but  slightly  covered  by 
peritoneum,  being  only  in  contact  with  that  mem- 
brane in  such  parts  as  are  not  in  relation  with 
the  cellular  tissue  at  the  back  of  the  colon  and  at 
the  back  of  the  duodenum  or  pancreas.  _  The  ex- 
ternal border  is  more  closely  in  connection  with 
the  peritoneum,  while  the  posterior  surface  is 
quite  devoid  of  that  membrane  (Figs.  65  and  66). 
Crossing  the  posterior  surface  of  the  kidney 
obliquely  from  above  downwards  and  outwards 
are  branches  of  the  last  dorsal  nerve  and  of  the 
first  lumbar  artery,  together  with  the  ilio-hypo- 
gastric  and  ilio-inguinal  nerves  (Fig.  68).  Rup- 
ture of  the  kidney  is  more  often  recovered  from 
than  is  a  like  lesion  of  any  other  of  the  more 
commonly  injured  abdominal  viscera.  This  de- 
pends upon  its  extensive  non-peritoneal  surface, 
whereby  the  extravasation  of  blood  and  urine  that 
follows  the  accident  is  very  often  entirely  extra- 
peritoneal. The  gland  may  be  readily  wounded 
from  behind  or  from  the  loin,  without  the  peri- 
toneum being  injured.  When  the  spine  is  much 
bent  forwards,  the  kidney  lies  in  the  angle  of  the 
bend,  at  a  part  where  the  flexion  of  the  column 
is  the  most  acute.  In  extreme  flexion,  therefore, 
of  the  spine,  it  may  be  squeezed  betweenthe  ilium 
and  the  lower  ribs.  Thus,  hematuria  is  not  un- 
common after  injuries  to  the  back  associated  with 
extreme  bending  of  the  spine  forwards,  as  when 
a  heavy  weight  falls  upon  the  bowed  shoulders. 

The  kidney  is  embedded  in  a  large  quantity 


Chap.  XVII]        ABDOMINAL    VISCERA  411 

of  loose  fatty  tissue  constituting  the  perirenal 
capsule,  and  suppuration  extending  in  this  tissue 
constitutes  a  perinephritic  abscess.  Such  an  ab- 
scess may  be  due  to  disease  of  the  kidney 
itself,  to  affections  of  the  adjacent  parts  (spine, 
colon,  etc.),  or  to  injuries.  The  pus  is  at  first 
in  front  of  the  quadratus  1  umbo  rum,  and  then 
usually  makes  its  way  through  that  muscle  or 
through  the  lumbar  fascia.  It  then  presents  itself 
at  the  outer  edge  of  the  erector  spinse,  having 
passed  between  the  adjacent  borders  of  the  ex- 
ternal oblique  and  latissimus  dorsi  muscles.  It 
may,  however,  spread  into  the  iliac  fossa,  or  ex- 
tend into  the  pelvis  along  the  loose  connective 
tissue  behind  the  descending  colon  and  rectum, 
or  open  into  the  colon  or  bladder,  or  even  into  the 
lung.  Most  rarely  of  all  does  it  perforate  the 
peritoneum.  Renal  abscess  usually  opens  upon 
the  non-peritoneal  surface  of  the  gland.  It  may 
open  into  the  adjacent  colon.  In  one  case  a  renal 
abscess,  due  to  stone,  made  its  way  from  the  right 
kidney  into  the  pyloric  end  of  the  stomach,  so 
that  a  communication  was  established  between 
those  two  organs.  The  perirenal  fat  is  of  much 
surgical  importance,  as  its  laxity  permits  of  a 
ready  enucleation  of  the  organ.  It  is  more  abund- 
ant behind  than  in  front.  When  this  tissue  has 
been  destroyed  or  modified  by  inflammation,  the 
kidney  becomes  fixed,  and  its  removal  a  matter  of 
great  difficulty.  This  is  illustrated  by  the  re- 
moval of  a  large  tuberculous  kidney  which  has 
been  long  diseased.  Besides  the  perirenal  cap- 
sule, the  kidney  also  possesses  its  proper  capsule, 
which  can  be  easily  stripped  from  the  normal 
orgam  Incision  of  the  capsule  has  been  proposed 
to   relieve  congested  conditions  of  the  kidney. 

Movable  kidney.— The  kidneys,  being  closely 
applied  to  the  diaphragm,  necessarily  follow  its 
respiratory  movements;  in  normal  breathing  the 
up  and  down  excursion  of  the  kidney  is  about 
h  an  inch  in  extent.  The  perirenal  capsule  in 
which  the  kidney  is  loosely  embedded  is  merely  a 


412  SUEGICAL   APPLIED    ANATOMY    [Part  IV 

specialised  part  _  of  the  subperitoneal  connective 
tissue;  above  it  is  continuous  with  the  dense  sub- 
peritoneal tissue  on  the  diaphragm,  externally 
with  the  equally  dense  layer  over  the  transversalis, 
internally  it  fuses  with  the  sheaths  of  the  in- 
ferior vena  cava  and  aorta,  while  below  it  is 
continued  downwards,  as  the  lax  subperitoneal 
tissue  surrounding  the  ureter,  to  become  con- 
tinuous with  the  corresponding  tissue  in  the 
pelvis.  Hence  only  downward  displacements  are 
possible.  The  perirenal  capsule  and  the  renal 
vessels,  while  they  restrict  and  determine  the 
direction  of  the  renal  movements,  only  come  into 
action  when  the  normal  limits  have  been  exceeded. 
The  force  which  retains  the  kidneys  in  position  is 
the  intra-abdominal  tension  maintained  by  the 
musculature  of  the  abdominal  wall,  by  which 
the  other  viscera  are  compressed  against  the  kid- 
neys. With  the  absorption  of  fat  from  the  cap- 
sule the  tissue  of  the  perirenal  capsule  becomes 
more  lax  and  the  renal  movements  more  free. 
Hence  movable  kidney  is  often  met  with  in  the 
badly  nourished.  It  is  far  more  common  in 
women  than  in  men.  In  the  former  sex  the  influ- 
ence of  pregnancy  appears  to  have  especial  effect, 
acting,  probably,  by  dragging  upon  the  peri- 
toneum, and  by  loosening  its  connections,  as  well 
as  by  inducing,  after  delivery,  a  general  laxity 
of  the  abdominal  walls.  The  right  kidney  is  far 
more  often  movable  than  is  the  left,  owing  prob- 
ably to  the  displacing  influence  of  the  liver.  I 
have  recorded  (in  conjunction  with  Dr.  Mac- 
lagan)  three  cases  in  which  a  movable  kidney 
pressed  against  the  neck  of  the  gall-bladder  and 
obstructed  the  flow  of  bile.  The  movable  kidney 
can,  of  course,  only  be  displaced  within  a  seg- 
ment of  a  circle  whose  radius  corresponds  to  the 
length  of  the  renal  vessels,  and  yet  this  displace- 
ment may  be  considerable.  # 

The  dragging  pains  which  are  felt  with  a 
movable  kidney  are  due  to  a  stretching  of  the 
renal  plexus,   which  is  connected  with  the  solar 


Chap.  XVII]  ABDOMINAL    VISCERA  413 

plexus  and  enters  the  kidney  with  the  arteries. 
The  kidney  receives  its  nerve  supply  from  the 
tenth,  eleventh,  twelfth  dorsal,  and  first  lumbar 
segments  of  the  spinal  cord  through  the  small  and 
lesser  splanchnics  (Head).  Pain  is  referred  to 
the  wall  of  the  abdomen  along  the  sensory  nerves 
derived  from  these  segments. 

Abnormalities  of  the  kidneys. — One,  or  less 
frequently  both,  kidneys  may  be  misplaced.  The 
left  is  more  often  out  of  place  than  the  right, 
and  may  be  found  over  the  sacro-iliac  synchon- 
drosis, or  the  promontory  of  the  sacrum,  or  be 
discovered  in  the  iliac  fossa  or  pelvis.  The  mis- 
placed kidney  is  often  misshaped.  The  kidney 
may  exhibit  a  more  or  less  extreme  degree  of 
lobulation,  a  condition  present  in  the  newly  born. 
The  ureter  may  be  double.  Supernumerary 
arteries  are  frequently  present;  cases  have  been 
recorded  where  such  vessels,  passing  to  the  lower 
pole  of  the  kidney,  have  caused  constriction  or 
kinking  of  the  ureter. 

The  two  kidneys  may  be  fused.  "  The  lowest 
degree  of  fusion  is  seen  in  the  horse-shoe  kidney. 
The  two  kidneys  are  united  at  their  inferior  por- 
tions by  a  flat,  riband-like,  or  rounded  bridge  of 
tissue,  which  crosses  the  vertebral  column.  In  the 
higher  degrees  the  two  lateral  portions  approach 
one  another  more  and  more  until  they  reach  the 
highest  degree,  in  which  a  single  disc-like  kidney, 
lying  in  the  median  line,  and  provided  with  a 
double  or  single  calyx,  represents  complete 
fusion"  (Rokitansky).  When _  the  two  kidneys 
are  united  by  a  web  of  connective  tissue,  the  con- 
dition is  no  bar  to  operation.  There  may  be  an 
entire  absence  of  one  kidney.  The  single  kidney 
may  he  lateral  or  median  in  position.  Henry 
Morris  gives  the  following  estimate  of  the  fre- 
quency of  these  abnormal  conditions  :  Congenital 
absence  or  extreme  atrophy  of  one  kidney  may  be 
expected  in  about  one  in  4,000  cases,  the  horse- 
shoe kidney  in  one  in  1,600,  and  the  single  fused 
kidney  in  one  in  8,000  cases. 


414 


SUKGICAL   APPLIED    ANATOMY    [Part  IV 


nc. Sinus 


LAR  Vein 

1/IMOMlNATE  art. 

Trachea 
«  Oesophagus 

Vena  Azyqos  Major 
Right  Luhc 
Thoracic  Duct 
Diaphraqm 

Richt  Kidney 
Ureter 
Spermatic  Vessels 

nf.  Vena  Cava 
Bifurcation  of  Aorta 
Cluteus  AIedius 
Psoas 
Rectum 

Sup.  AIaemorrh.Art. 
Gluteus  Maximus 


Fig.  69.— View  of  the  kidneys,  etc.,  from  behind.    (After  RMinger.) 


Chap.  XVII]         ABDOMINAL    VISCERA  415 

■  5j  Operations  on  the  kidney. — (1)  Nephrotomy. 
Incision  into  the  kidney  for  exploration,  or  the 
evacuation  of  pus.  (2)  Nephro-lithotomy.  In- 
cision into  the  gland  for  the  removal  of  a  calculus. 

(3)  Nephrectomy.     Removal  of  the  entire  organ. 

(4)  Nephroraphy.  The  operation  of  securing  a 
movable  kidney  in  its  normal  position.  In  the 
first,  second,  and  fourth  operations  the  kidney 
is  reached  through  the  loin  by  an  oblique  incision, 
such  as  is  used  in  colotomy  (p.  392),  the  cut, 
however,  being  carried  a  little  farther  backwards. 
In  nephrectomy  a  like  incision  may  be  used.  The 
cut  is  carried  backwards  about  1  inch  over  the 
erector  spinse,  and  a  part  of  the  quadratus  lum- 
borum  will  probably  have  to  be  divided.  The 
costo-vertehral  ligament,  a  specialised  part  of 
the  middle  layer  of  the  lumbar  fascia  which 
binds  the  last  rib  to  the  tips  of  the  upper 
two  lumbar  transverse  processes,  also  falls  in 
the  line  of  the  incision.  The  perirenal  tissue 
is  opened  up,  and  the  gland  enucleated  from 
the  capsule  of  fat  in  which  it  lies.  In 
some  instances  the  last  rib  has  been  resected  to 
obtain  more  space  for  the  operation.  The  pleura 
reaches  the  neck  of  the  twelfth  rib  and  occasion- 
ally it  descends  as  far  as  the  transverse  process 
of  the  first  lumbar  vertebra  (Figs.  65  and  68).  In 
one  case  the  twelfth  rib  was  rudimentary,  and  the 
eleventh  rib  was  removed  under  the  impression 
that  it  was  the  twelfth.  The  pleura  was  opened 
and  death  ensued. 

When  the  kidney  is  free  from  its  fatty  capsule, 
the  vessels  at  the  hilum  are  secured  separately  by 
ligatures.  The  numerous  nerves  to  the  kidney 
are  no  doubt  included  with  the  vessels.  They  con- 
stitute a  surgical  pedicle  of  the  kidney.  At  the 
hilum  the  vein  lies  in  front,  the  artery  and  its 
branches  next,  and  the  ureter  behind  and  towards 
the  lower>  part.  The  artery  is  about  the  size  of 
the  brachial,  and  usually  divides  into  four,  five, 
or  _  six  branches  before  it  reaches  the  kidney. 
This  fact  must  be  borne  in  mind  if  the  structures 


416  SUEGICAL   APPLIED   ANATOMY    [Part  IV 

at  the  hilum  are  separately  secured.  One-third 
of  these  branches  constantly  enter  the  hilum  be- 
hind the  ureter  and  are  liable  to  injury  in  ex- 
ploration of  the  pelvis  of  the  kidney.  The  vein 
is  also  represented  at  the  hilum  by  three  or  four 
branches.  Accessory  renal  arteries  may  be  present. 
Some  may  enter  the  upper  end  of  the  kidney  or  its 
anterior  surface.  In  removing  large  renal  tumours 
an  abdominal  incision  is  advised,  the  cut  being 
made  either  along  the  corresponding  semilunar 
line,  and  on  a  level  with  the  diseased  mass,  or  in 
the  linea  alba.  The  abdominal  operation  is  the 
more  usual  one,  and  has  the  advantages  of  greater 
ease  and  rapidity  in  performance  and  gives  an 
opportunity  of  examining  the  condition  of  both 
kidneys.  In  chronically  inflamed  conditions  of 
the  kidney — as,  for  example,  in  long  standing 
tuberculous  disease — the  kidney  becomes  adherent, 
and  on  the  right  side  is  apt  to  become  closely 
bound  down  to^  the  vena  cava.  _  Much  care  is 
needed  in  clearing  the  great  vein  when  so  ad- 
herent. In  removing  a  very  adherent  kidney  the 
diaphragm  has  been  torn. 

The  ureters  are  strong  tubes  about  15  inches 
long,  with  thick  muscular  walls,  and  are  placed 
entirely  behind  the  peritoneum.  The  average 
width  is  that  of  a  goose-quill.  The  ureter  rests 
from  above,  downwards  upon  (1)  the  psoas  muscle 
and  the  genito-crural  nerve ;  (2)  the  common  iliac 
vessels  on  the  left  side,  and  the  external  iliac 
vessels  on  the  right;  (3)  after  passing  downwards 
on  the  internal  iliac  artery  it  then  enters  the 
posterior  false  ligament  of  the  bladder,  and  so 
reaches  the  bladder  wall.  In  the  female  it  passes 
through  the  base  of  the  broad  ligament,  where  the 
uterine  artery  loops  over  it  f  of  an  inch  from  the 
neck  of  the  uterus.  It  rests  on  the  roof  of  the 
upper  part  of  the  vagina  before  entering  the 
bladder,  and  a  calculus  arrested  in  that  stage  may 
be  distinctly  felt.  The  narrowest  part  of  the 
tube  is  the  portion  within  the  bladder  walls,  and 
when  renal  calculi  pass  along  the  ureter  they  are 


Chap.  XVII]         ABDOMINAL    VISCERA  417 

often  arrested  at  this  point.  There  are  two  other 
narrow  points  at  which  calculi  may  be  stopped  : 
at  its  junction  with  the  pelvis  of  the  kidney,  and 
where  it  crosses  the  pelvic  brim.  The  ureters  per- 
mit of  great  distension,  and  in  certain  cases  of 
gradual  dilatation  they  have  attained  a  width 
equal  to  that  of  the  thumb  and  even  of  the  small 
intestine.  Several  cases  are  recorded  of  rupture 
of  the  ureter  from  external  violence.  When  such 
an  accident  occurs  a  large  urinary  collection 
usually  forms  behind  the  peritoneum,  which,  lead- 
ing to  suppuration,  will  produce  a  fluctuating 
tumour  beneath  the  parietes. 

The  ureter  expands  in  the  hilum  of  the  kidney 
into  a  funnel-shaped  cavity — the  pelvis.  This  in 
turn  divides  into  the  calyces.  In  the  pelvis  or 
calyces,  calculi  are  frequently  lodged.  The  calyces 
are  too  narrow  to  admit  an  exploring  finger. 
The  ureter  has  been  successfully  resected  and 
sutured.  It  is  supplied  by  nerves  from  the  renal 
plexus  and  by  vessels  from  the  renal,  inferior 
vesical  and  subperitoneal  plexus. 

In  the  search  for  impacted  calculi  by  the  aid 
of  X-rays  the  following  method  will  be  found 
useful  for  indicating  the  course  of  the  ureter. 
The  pelvis  of  the  kidney  lies  between  the  trans- 
verse processes  of  the  two  upper  lumbar  vertebrae 
(Fig.  TO)  ;  its  position  on  the  surface  of  the  body 
may  be  indicated  by  taking  a  point  just  internal 
to  that  used  for  the  gall-bladder  (p.  396).  At 
the  brim  of  the  pelvis  the  ureter  crosses  at  or 
near  the  bifurcation  of  the  common  iliac  artery, 
a  point  which  lies  at  the  junction  of  the  upper 
with  the  lower  two-thirds  of  a  line  drawn  from 
the  aortic  bifurcation  to  the  femoral  point  (see 
Figs.  TO  and  57,  pp.  418  and  340).  Its  pelvic 
course  is  curved  (Fig.  TO),  the  convexity  of  its  out- 
ward bend  lying  \  an  inch  in  front  of  the  ischial 
spine.  The  vesical  orifice  is  to  be  sought  for  in 
a  skiagram  at  some  distance  above  and  internal 
to  the  pubic  spines.  Mr.  Rigbjr  has  shown  that 
the  ureter  may  be  exposed  from  behind  through 
2  B 


418 


SUKGICAL   APPLIED    ANATOMY    [Part  IV 


the  sacro-sciatic  notch  and  calculi  thus  removed 
from  it  when  the  anterior  operation  is  imprac- 
ticable on  account  of  pelvic  adhesions.  He  uses 
the  ischial  spine  as  a  guide  in  finding  the  ureter. 
The  nerve  supply  of  the  abdominal  viscera. 
— Some  account  has  already  been  given  of  these 


rIBAE  1/tRTEBOA 
IS  OF  KlDfEV 


ETEB 
MBIUCUS 

Aootic  Bifurcation 


FtJrtDl!\5  ofUTERUS 

Ubetes 


Fig.  70.— Diagram  to  show  the  course  of  the  ureters  and  position  of  the 

bladder, 

As  they  appear  in  a  skiagram  when  they  have  been  injected  with  a  bismuth 
solution.  The  positions  of  the  fundus  of  the  uterus,  Fallopian  tubes  and 
ovaries  are  also  indicated. 


nerves  and  the  spinal  segments  from  which  they 
are  derived  (p.  337).  The  abdominal  viscera 
are  mainly  supplied  by  the  sympathetic  system 
through  a  series  of  remarkable  plexuses.  The 
most  important  of  these  is  the  solar,  from  which 
is  more  or  less  directly  derived  the  nerve  supply 
of  the  stomach,  liver,  spleen,  kidneys,  suprarenal 


Chap.  XVII]        ABDOMINAL    YISCEEA  419 

capsules,  pancreas,  and  such  parts  of  the  intestine 
as  are  in  connection  with  the  superior  mesenteric 
artery.  The  solar  plexus  and  its  appendages  re- 
ceive the  splanchnic  nerves  and  some  branches 
from  the  vagus,  while  communications  from  the 
phrenic  go  to  the  hepatic  and  suprarenal  plexuses. 
Through  these  nerves  the  calibre  of  the  blood- 
vessels and  the  amount  of  blood  in  the  abdomen 
are  regulated.  They  contain  not  only  sensory 
fibres  for  the  abdominal  viscera  but  constrictor 
and  dilator  fibres  for  the  bowel.  It  may  be  well 
understood  that  an  impression  brought  to  bear 
upon  extensive  net-works  with  such  wide  central 
connections  and  with  such  important  relations 
would  produce  considerable  effects.  These  effects 
we  see  in  the  profound  collapse,  vomiting,  and 
other  grave  symptoms  that  attend  severe  injuries 
to  the  viscera,  and  especially  to  those  that  are  the 
most  directly  associated  with  these  large  plexuses. 
The  descending  colon  and  sigmoid  flexure  are  sup- 
plied by  the  inferior  mesenteric  plexus,  a  cord 
that  has  but  an  indirect  connection  with  the  solar 
plexus :  and  this  fact  may  serve  to  account  for  the 
less  serious  symptoms  often  seen  in  strangulation 
of  the  colon  when  compared  with  a  like  lesion 
of  the  small  gut.  The  upper  part  of  the  colon, 
although  supplied  by  the  superior  mesenteric 
plexus,  is  only  supplied  by  that  part  of  it  that 
is  most  remote  from  the  great  centres,  and  it  is 
a  conspicuous  fact  that  the  nearer  the  lesion  is  to 
the  stomach,  the  graver,  other  things  being  equal, 
are  the  nervous  phenomena  produced.  It  would 
appear  that  some  lesion  of  these  nerve  plexuses 
is  sometimes  active  in  producing  a  remarkable 
pigmentation  of  the  skin.  This  is  seen  in  Addi- 
son's disease,  a  disease  marked  by  a  general  bronz- 
ing of  the  surface,  and  usually  associated  with 
some  disintegration  of  the  suprarenal  capsules. 
The  very  direct  relation  of  these  bodies  to  the 
solar  plexus  is  well  known.  In  pregnancy  also, 
in  abdominal  tuberculosis,  in  cancer  of  the 
stomach,  and  in  liver  diseases,  a  pigmentation  of 


420  SUEGICAL   APPLIED    ANATOMY    [Part  IV 

the  face  is  sometimes  seen,  that  may  in  such 
instances  be  probably  ascribed  to  a  disturbance 
of  the  great  abdominal  nerve  centres. 

In  some  diseases  of  the  liver  and  stomach 
"  sympathetic  ';  pains  are  complained  of  between 
the  shoulders  or  about  the  inferior  angles  of  the 
scapulae.  They  commonly  appear  some  distance 
below  the  angle  of  the  scapula.  The  nerves  for 
the  stomach  are  derived  principally  from  the 
seventh  and  eighth  and  those  for  the  liver  from 
the  eighth  and  ninth  spinal  segments.  The  skin 
areas  of  these  segments  may  become  tender  when 
the  organs  are  diseased  and  to  some  point  in 
these  areas  pain  is  referred  (Fig.  56,  p.  333).  The 
shoulder-tip  pain  that  often  accompanies  liver 
disease  is  situated  in  the  area  supplied  by  the 
fourth  cervical  segment,  the  same  segment  as  sup- 
plies sensory  fibres  to  the  diaphragm  and  sub- 
diaphragmatic connective  tissue  through  the 
phrenic  nerves.  It  will  be  remembered  that  these 
nerves  are  distributed  on  the  under  surface  of  the 
diaphragm. 

There  would  seem  to  be  but  little  connection 
between  a  disease  in  the  sigmoid  flexure  and  a 
pain  in  the  knee,  yet  in  cases  of  cancer  in  the 
flexure,  and  in  instances  where  it  has  been  dis- 
tended with  fseces,  such  pain  has  been  complained 
of.  The  pain  is  conveyed  along  the  obturator 
nerve,  which  lies  beneath  the  sigmoid  flexure, 
and  could  be  readily  pressed  upon  by  the  gut 
when  diseased.  Pain  arising  from  the  small  in- 
testine is  usually  referred  to  the  neighbourhood 
of  the  umbilicus — the  distribution  of  the  tenth 
dorsal  nerve  (Fig.  56,  p.  333).  It  seems  remark- 
able that  such  pains  should  be  restricted  to  so 
narrow  an  area,  but  a  full  explanation  of  this 
is  to  be  found  in  the  fact  that  the  whole  of  the 
small  intestine  arises  from  an  extremely  small 
part  of  the  embryonic  alimentary  tract.  Pains 
along  the  groin  (along  the  twelfth  dorsal  and  first 
lumbar  nerves)  arise  from  many  sources — from 
disease    of    the    kidney,    ureter,    ovary,    testicles, 


Chap.  XVII]        ABDOMINAL    VISCERA  421 

Fallopian  tubes,  uterus,  appendix,  hip-joint,  and 
from  hernia?. 

The  blood-vessels  of  the  abdomen. — Some 
of  the  visceral  branches  of  the  abdominal  aorta 
are  of  large  size,  and  would  bleed  very  copiously 
if  wounded.  Thus,  the  coeliac  axis  and  the 
superior  mesenteric  artery  are  as  large  as  the 
common  carotid ;  the  splenic,  hepatic,  and  renal 
vessels  are  about  the  size  of  the  brachial;  while 
the  largest  part  of  the  inferior  mesenteric  trunk 
has  dimensions  equal  to  those  of  the  ulnar  artery. 
Aneurisms  of  the  aorta  are  especially  apt  to  occur 
at  the  coeliac  axis,  that  being  a  point  where  a 
number  of  large  branches  are  abruptly  given  off, 
and  where  the  course  of  the  circulation  undergoes 
in  consequence  a  sudden  deviation.  Although 
two,  or  in  some  places  three,  anastomotic  arches 
occur  between  the  branches  of  the  superior  mesen- 
teric artery  before  they  form  a  final  net-work  in 
the  bowel,  yet  embolism  of  a  comparatively  small 
branch  may  lead  to  gangrene  of  the  gut  (Lock- 
wood). 

When  it  is  remembered  that  the  lumbar  glands 
lie  about  the  vena  cava  and  iliac  veins,  it  will 
be  understood  that  great  enlargement  of  those 
bodies  may  cause  cedenia  from  pressure.  Gan- 
grene of  the  whole  of  the  small  intestine  may 
result  from  an  embolism  of  the  portal  vein.  In 
a  case  reported  by  Mr.  Barnard  the  embolism  was 
caused  by  a  constriction  at  the  point  where  the 
vein  passes  behind  the  neck  of  the  pancreas.  The 
inferior  vena  cava  has  been  ligatured  success- 
fully ;  amongst  the  collateral  veins  which  enlarge, 
the  chief  are  the  azygos,  epigastric,  and  intra- 
vertebral  veins. 

A  number  of  minute  but  most  important  anas- 
tomoses exist  between  some  of  the  visceral  branches 
of  the  abdominal  aorta  and  certain  of  the  vessels 
supplied  to  the  abdominal  parietes.  These  anasto- 
moses are  situated  behind  the  peritoneum,  and 
mostly  concern  such  viscera  as  have  a  fair  surface 
uncovered     by     that     membrane.       The      visceral 


422  SUEGICAL   APPLIED    ANATOMY    [Part  IV 

branches  that  join  the  anastomoses  are  derived 
from  the  hepatic,  renal,  and  suprarenal  arteries, 
and  from  the  vessels  supplying  the  lower  part  of 
the  duodenum,  the  pancreas,  the  csecum,  and  the 
ascending  and  descending  segments  of  the  colon. 
The  parietal  vessels  joining  with  the  above  are 
derived  from  the  phrenic,  lumbar,  ilio-lumbar, 
lower  intercostal,  epigastric,  and  circumflex  iliac 
trunks.  In  a  case  detailed  by  Professor  Chiene 
{Joum.  Anat.  and  Phys.,  vol.  iii.)  the  cceliac 
axis  and  mesenteric  vessels  were  plugged,  but 
blood  in  sufficient  amount  to  supply  the  viscera 
had  reached  branches  of  these  arteries  through 
their  parietal  communications.  When  the  portal 
circulation  becomes  obstructed  owing  to  disease  of 
the  liver,  blood  from  the  portal  vein  may  pass 
into  the  systemic  veins  at  the  following  points  : 

(1)  lower  part  of  the  rectum,  from  the  superior 
to  the  inferior  and  middle  hemorrhoidal  veins; 

(2)  at  the  oesophagus,  from  the  coronary  to  the 
oesophageal  veins;  (3)  in  the  falciform  and  round 
ligaments,  from  the  portal  vein  to  tributaries  of 
the  epigastric ;  (4)  in  the  subperitoneal  tissue  of 
the  posterior  wall  of  the  abdomen,  whereby  the 
renal,  phrenic,  lumbar,  and  intercostal  veins  re- 
ceive blood  from  mesenteric,  pancreatic,  and  other 
veins.  By  bringing  about  adhesions  between  the 
omentum  or  visceral  peritoneum  and  the  parietal 
peritoneum,  as  is  done  in  the  Talma-Morrison 
operation,  new  and  large  communications  are 
formed  between  the  portal  and  systemic  venous 
circulations.  Cases  have  been  recorded  of  com- 
munications between  the  external  iliac  vein  and 
the  portal  vein.  These  have  generally  been 
effected  by  the  deep  epigastric  vein  joining  with 
a  pervious  umbilical  vein  in  the  vicinity  of  the 
navel. 

Thoracic  duct. — The  thoracic  duct  may  be 
wounded  in  the  course  of  removing  tubercular 
glands  from  beneath  the  lower  part  of  the  left 
sterno-mastoid ;  or,  as  in  some  reported  cases,  may 
be  severed  by  a  stab  in  the  neck.     In  each  case 


Chap.  XVII]        ABDOMINAL    VISCERA  423 

lymph  and  chyle  in  large  quantities  escaped 
from  the  wound.  The  duct  has  been  found  to 
have  been  obliterated,  and  that,  too,  without  pro- 
ducing any  marked  symptoms  during  life.  It  has 
been  cut  and  ligatured  during  removal  of  glands 
from  the  supraclavicular  triangle,  with  no  bad 
result.  Mr.  Leaf  has  shown  that  the  thoracic 
duct  communicates  freely  with  the  azygos  veins 
in  the  posterior  mediastinum  and  with  the  lym- 
phatic vessels  of  the  right  side  of  the  thorax  and 
neck.  It  frequently  serves  as  a  channel  for  the 
spread  of  malignant  tumours  situated  in  the 
upper  part  of  the  abdomen.  Enlargement  of  the 
inferior  deep  cervical  glands  in  the  left  side  of  the 
neck  niav  be  the  first  sign  of  cancer  of  the  stomach 
(W.  M.  'Stevens). 


CHAPTER    XVIII 
THE    PELVIS   AND    PERINEUM 

The  mechanism  of  the  pelvis. — Besides  form- 
ing a  cavity  for  certain  viscera,  a  support  for 
some  abdominal  organs,  and  a  point  for  the  at- 
tachment of  the  lower  limb  and  of  many  muscles, 
the  pelvis  serves  to  transmit  the  weight  of  the 
body  both  in  the  standing  and  sitting  postures. 
The  transmission  is  effected  through  two  arches, 
one  available  for  the  erect  position,  the  other  for 
the  posture  when  sitting.  When  standing,  the 
arch  is  represented  by  the  sacrum,  the  sacro-iliac 
synchondroses,  the  acetabula,  and  the  masses  of 
bone  extending  between  the  two  last-named  points. 
If  all  other  parts  of  the  pelvis  were  to  be  cut 
away  but  these2  the  portions  left  would  still  be 
able  to  support  the  weight  of  the  body,  and  would 
represent  in  its  simplicity  the  arch  through  which 
that  weight  is  transmitted.  When  sitting,  tb?  arch 
is  represented  by  the  sacrum,  the  sacro-iliac  syn- 
chondroses, the  tubera  ischii,  and  the  strong 
masses  of  bone  that  extend  between  the  two  last- 
named  parts.  Morris  terms  these  two  arches  the 
femoro-sacral  and  the  ischio-sacral.  On  examin- 
ing the  innominate  bone  it  will  be  seen  that  its 
thickest  and  strongest  parts  are  such  as  are  situ- 
ate in  the  line  of  these.  '  When  very  considerable 
strength  is  requisite  in  an  arch,  it  is  continued 
into  a  ring  so  as  to  form  a  counter-arch,  or  what 
is  called  a  tie  is  made  to  connect  together  the 
ends  of  the  arch,  and  thus  to  prevent  them  from 

424 


Chap.  XVIII]      PELVIS    AND    PERINEUM  425 

starting  outwards.  By  these  means  a  portion  of 
the  superincumbent  weight  is  conveyed  to.  the 
centre  of  the  counter-arch,  and  borne  in  what  is 
called  the  sine  of  the  arch.  The  body  and  hori- 
zontal rami  of  the  pubes  form  the  tie  or  counter- 
arch  of  the  femoro-sacral,  and  the  united  rami  of 
the  pubes  and  ischium  the  tie  of  the  ischio-sacral 
arch.  Thus  the  ties  of  both  arches  are  united  in 
front  at  the  symphysis  pubis,  which,  like  the 
sacrum  or  keystone,  is  common  to  both  arches. 
.  .  .  .  This  explains  how  it  is  that  so  much 
strain  is  made  upon  the  symphysis  when  any 
increased  weight  has  to  be  supported  by  the  pelvis, 
as  in  pregnancy ;  why  there  is  such  powerlessness, 
with  inability  to  stand  or  sit,  in  cases  in  which 
this  joint  is  weakened  or  diseased;  and  why  the 
anterior  portion  of  the  pelvis  yields  under  the 
weight  of  the  body  and  becomes  deformed  in 
rickets  and  mollities  ossium."  *  The  pelvic  de- 
formity in  rickets,  it  may  be  here  observed,  varies 
greatly  according  to  the  age  at  which  the  disease 
sets  in,  and  the  usual  attitude  of  the  child  when 
it  becomes  affected.  The  deformity  sometimes  pro- 
duced in  very  young  infants  has  been  ascribed 
to  muscular  contraction  (ilio-psoas,  erector  spinse, 
gluteus  medius,  etc.).  In  the  rickety  pelvis,  par 
excellence,  the  two  acetabula  approach  one 
another,  the  anterior  part  of  the  pelvis  yields,  so 
that  the  symphysis  is  pushed  forward,  and  the 
cavity  becomes  greatly  narrowed  in  its  transverse 
diameter.  In  severe  cases  the  anterior  arch  may 
practically  collapse,  and  the  horizontal  rami  of 
the  pubes  be  for  some  little  way  parallel  to  one 
another. 

In  the  erect  attitude  the  pelvis  is  so  inclined 
that  the  plane  of  the  brim  of  the  true  pelvis  forms 
with  the  horizon  an  angle  of  from  60°  to  65°;  the 
base  of  the  sacrum  is  about  3|  inches  above  the 
upper  border  of  the  symphysis,  while  the  tip  of 
the  coccyx  is  a  little  higher  than  its  lower  border. 

*  Henry  Morris   on    "The   Joints,"   p.  116,    where   a   most    valuable 
account  of  the  mechanism  of  the  pelvis  will  be  found. 


426  SURGICAL   APPLIED    ANATOMY    [Part  IV 

The  centre  of  gravity  of  the  whole  body  (adult) 
is  at  a  spot  just  above  the  sacro-lumbar  angle, 
and  exactly  over  the  mid-point  of  a  line  drawn 
between  the  heads  of  the  femora. 

Fractures    of  the    pelvis. — From  what  has 
been   already  said,   it  may  be  surmised  that  the 
weakest  parts  of  the  pelvis  are  at  the  symphysis 
and   the    sacro-iliac    joints.     The   bones    of    these 
parts,   however,   are  so  very  firmly  knit  together 
by   powerful   ligaments  that  it  is  very   rare   for 
these  articulations  to  give  way,   fracture  of  the 
adjacent   bones   being   more   common.     The   com- 
monest   fracture    of    the    pelvis    is    in    the    weak 
counter  arch,   and  involves  the  rami  of  both  the 
pubes    and    the    ischium.   .  The    fracture    is    often 
associated  with  some  tearing  of  ligaments  about 
the  sacro-iliac  synchondrosis,  and  is  met  with  in 
accidents   due  to  the  most  varied   forms  of  vio- 
lence.    This  last  remarkable  circumstance  is  thus 
explained  by  Tillaux.     If  the  pelvis  be  compressed 
in    (a)    an    antero-posterior    direction,    the    main 
brunt  of  the  force  comes  upon  the  weak  counter 
arch,   which  fractures  from  direct  violence.     The 
force,  continuing,  tends  to  push  asunder  the  two 
iliac  bones,  and  so  cause  rupture  of  the  anterior 
ligaments  at  the  sacro-iliac  joint.     If  the  force  be 
applied  (b)  transversely,  the  two  acetabula  tend 
to   be   pressed  towards  one   another,    the   counter 
arch  becomes  more  bent,  and  ultimately  gives  way 
by   indirect   violence.     The   violence,    continuing, 
forces  the  two  ilia  towards  one  another,  the  strain 
then  falls  upon  the  sacro-iliac  synchondrosis,  and 
the  posterior  ligaments  of  that  joint  are  apt  to 
yield,  or  portions  of  the  bone  adjacent  to  the  joint 
are  torn  away.     In  cases  of  falls,  when  the  patient 
alights   upon   the   feet  or   ischial   tuberosities,    it 
can  be  understood  how  in  many  instances  the  main 
arches   will   escape   injury   owing   to   their   great 
strength,    while   the    counter    arch   becomes   frac- 
tured.    Any    part    of    the    pelvis,    including    the 
sacrum,    may   be   broken   by   well-localised   direct 
violence.     More  or  less  of  the  iliac  crest,  the  an- 


Chap.  XVIII]       PELVIS    AND    PERINEUM  427 

terior  superior  and  posterior  superior  spines, 
have  been  knocked  off.  The  first-named  part  may 
be  separated  as  an  epiphysis.  It  joins  the  bone 
at  about  the  twenty-fourth  year.  In  one  case  the 
anterior  inferior  spinous  process  was  torn  off  by 
the  rectus  muscle  during  the  act  of  running  a 
race.  The  os  innominatum  has  been  broken  into 
its  three  anatomical  portions.  This  accident  can- 
not take  place  after  about  the  seventeenth  year, 
since  by  that  time  the  Y-shaped  cartilage  is 
usually  fully  ossified,  and  the  three  elementary 
bones  are  fully  united.  Before  such  consolidation 
occurs,  abscess  in  the  hip-joint  not  unfrequently 
makes  its  way  through  the  cartilage  into  the 
pelvis.  The  acetabulum  has  been  fractured,  and 
the  head  of  the  femur  driven  through  its  thinnest 
part  into  the  pelvis.  In  fractures  of  the  pubes 
and  ischium  the  bladder  has  been  torn  by  the 
sharp  fragments.  In  one  case  a  loose  piece  of 
bone  that  had  been  driven  into  the  bladder  became 
the  nucleus  for  a  stone.  The  urethra  and  vagina 
also  have  been  lacerated  or  seriously  compressed 
by  the  displaced  bones.  In  fractures  of  the 
sacrum  the  rectum  has  been  torn,  or  has  been  so 
compressed  by  the  lower  fragment  (which  is  al- 
most always  carried  forwards)  as  to  be  nearly 
closed. 

Special  parts  of  the  pelvis.  Symphysis.— 
Separation  of  the  bones  at  the  symphysis  without 
fracture  has  occurred  from  severe  violence.  Mal- 
gaigne  reports  three  cases  where  the  separation  was 
brought  about  by  muscular  violence  only,  by  ex- 
treme action  of  the  adductor  muscles  of  the  two 
sides.  The  Sigaultean  operation  consisted  in 
dividing  the  symphysis  pubis  in  cases  of  con- 
tracted pelvis,  with  the  idea  of  obtaining  more 
room  during  labour,  and  of  so  avoiding  Csesarian 
section.  The  union  consists  of  fibro-cartilage  and 
transverse  peripheral  fibrous  bands.  It  varies  in 
depth  from  lh  to  If  inch,  and  may  be  divided 
subcutaneously,  when  the  bones  gape  quite  i  an 
inch.     It  has  been  shown,   however,   that  to  gain 


428  SUKGICAL    APPLIED    ANATOMY    [Part  IV 

4  an  inch  in  the  anteroposterior  diameter  the 
bones  must  be  separated  to  the  extent  of  2  inches. 
Such  a  separation  involves  laceration  of  the  sacro- 
iliac ligaments,  and  more  or  less  damage  to  the 
attachments  of  the  pelvic  viscera. 

The  sacro-iliac  synchondrosis  may  be  the 
seat  of  disease.  Normally,  there  is  a  synovial 
space  and  a  slight  degree  of  movement  in  this 
joint.  As  this  joint  lies  in  the  line  of  the  great 
arches  of  the  pelvis,  it  follows  that  when  inflamed, 
much  pain  is  felt  in  the  part,  both  when  the 
patient  is  standing  and  when  sitting.  When 
abscess  forms  it  tends  to  come  forwards,  owing  to 
the  anterior  ligaments  being  slight  while  the  pos- 
terior ligament  is  dense,  thick,  and  of  great 
strength.  Having  reached  the  pelvic  aspect  of  the 
joint,  the  pus  may  occupy  the  iliac  fossa,  or  gain 
the  ilio-psoas  sheath.  Or  it  may  follow  the  lumbo- 
sacral cord  and  great  sciatic  nerve  and  point  in 
the  thigh  behind  the  great  trochanter,  or  it  may 
be  guided  by  the  obturator  vessels  to  the  inner  side 
of  the  thyroid  foramen,  and  ultimately  appear  at 
the  inner  side  of  the  thigh.  The  abscess  may, 
however,  proceed  backwards,  and  point  over  the 
posterior   aspect  of  the  joint. 

The  nerve  relations  of  this  joint  are  important. 
It  is  supplied  by  the  superior  gluteal,  by  the 
lumbo-sacral  cord  and  the  first  sacral  nerve,  and 
bv  the  first  and  second  posterior  sacral  nerves 
(Morris).  The  lumbo-sacral  cord  and  the  obtura- 
tor nerve  pass  over  the  front  of  the  joint,  the 
former  being  very  closely  connected  with  the 
articulation.  It  will  be  understood  from  these 
relations  that  in  sacro-iliac  disease  pain  is 
felt  over  the  sacral  region  (upper  sacral  nerves) 
and  in  the  buttock  (gluteal  nerve).  Much  pain 
is  also  often  complained  of  in  the  hip  or  knee- 
joint,  and  along  the  inner  part  of  the  thigh  (ob- 
turator nerve).  In  one  or  two  reported  cases 
there  has  been  severe  pain  in  the  calf  and  back  of 
the  thigh,  with  painful  twitchings  in  the  muscles 
of  those  parts  (lumbo-sacral  cord  and  connection 


Chap.  XVIIIJ      PELVIS    AND    PERINEUM  429 

with  great  sciatic  nerve).  Dislocation  of  the 
sacrum  at  this  joint  is  prevented  by  the  remark- 
able double  wedge-shaped  outline  of  the  bone,  and 
by  the  very  dense  ligaments  that  bind  it  in  its 
place.  The  bone  is  set  very  obliquely,  so  that 
the  weight  of  the  body  tends  to  force  its  base  into 
the  pelvis  and  tilt  its  apex  upwards.  The  strong 
posterior  sacro-iliac  ligaments  prevent  the  first 
movement,  the  great  sacro-sciatic  the  second. 

Trendelenburg's  operation. — In  order  to  bring 
the  two  pubic  bones  and  the  deficient  soft  parts 
together  in  ectopia  vesicas,  Trendelenburg  divides 
the  sacro-iliae  synchondroses  on  either  side.  The 
operation,  which  has  been  very  succcessful,  is 
limited  to  children  between  the  ages  of  two  and 
five.  The  distance  between  the  anterior  superior 
iliac  spines  has — in  a  child  aged  two  and  a  half 
years — been  lessened  2  inches  by  this  operation. 

Sacro-coccygeal  tumours. — The  sacro-coccygeal 
region  is  very  often  the  seat  of  congenital  tumours, 
some  of  them  of  such  a  shape  as  to  form  "  human 
tails  "  ;  and  to  this  part  of  the  pelvis  has  also 
been  found  attached  a  third  lower  limb  leading 
to  the  condition  known  as  "  tripodism." 

Parasitic  foetuses  are  also  frequently  found 
attached  to  this  segment  of  the  spine.  In  many  of 
the  instances  of  attached  foetuses  the  two  in- 
dividuals have  been  joined  together  at  this  part 
of  the  column.  Some  of  the  sacro-coccygeal 
tumours  contain  epithelial  cysts  and  fragments  of 
skin,  muscle,  nerve,  bone,  cartilage,  and  mucous 
membrane.  These  strange  masses  spring  from  the 
anterior  part  of  the  coccyx,  between  it  and  the 
rectum.  By  some  they  are  supposed  to  arise  from 
coccygeal  body,  by  others  (Sutton)  from  the  struc- 
tures known  to  embryologists  as  the  postanal  gut 
and  the  neurenteric  passage. 

The  sacro-coccygeal  joint  may  be  dislocated 
or  diseased.  In  either  affection  great  pain  is  kept 
up  from  the  frequent  movement  of  the  part  by  the 
muscles  attached  to  the  coccyx  (the  gluteus  niaxi- 
mus,   coccygeus,   levator  ani,   and  sphincter).     In 


430  SURGICAL   APPLIED    ANATOMY    [Part  IV 

the  luxation  the  bone  may  project  into  the  rectum, 
and  thus  give  trouble.  The  joint  and  the  parts 
about  it  may  be  the  seat  of  such  severe  neuralgia 
("  coccygodynia  ")  as  to  require  excision  of  the 
coccyx,  or  a  free  division  of  the  structures  that 
cover  it  behind.  The  joint  and  the  fibrous  tissue 
about  it  are  supplied  by  the  following  nerves  :  the 
posterior  divisions  of  the  second,  third,  and 
fourth  sacral,  and  the  anterior  and  posterior 
divisions  of  the  fifth  sacral  and  coccygeal.  In  old 
age  the  coccyx  becomes  ossified  to  the  sacrum. 

The  floor  of  the  pelvis  and  the  _  pelvic 
fascia.  —  The  outlet  of  the  bony  pelvis  is  occu- 
pied in  the  recent  state  by  the  following  struc- 
tures from  behind  forwards  :  the  pyriformis,  the 
sacro-sciatic  ligaments,  the  coccygeus,  the  levator 
ani,  and  the  triangular  ligament  of  the  perineum. 
These  form  the  floor  of  the  pelvis.  The  three 
structures  last  named  serve  to  separate  the  pelvic 
cavity  from  the  perineum  and  provide  a  ham- 
mock-like support  for  the  viscera  of  the  pelvis. 

The  walls  and  floor  of  the  pelvis  are  lined  by 
a  fascia,  the  pelvic  fascia,  of  which  a  brief  general 
description  may  be  given.  This  fascia  is  divided 
into  two  distinct  parts,  a  parietal  layer  and  a 
visceral  layer,  (l)  The  parietal  layer  begins  at 
the  brim  of  the  true  pelvis,  to  which  it  is  at- 
tached. From  this  attachment  it  passes  down 
along  the  pelvic  wall,  forming  a  lining  for  that 
part,  covering  in  the  obturator  internus  muscle, 
and  becoming  adherent  below  to  the  rami  of  the 
pubes  and  ischium,  and  to  the  tuber  ischii.  More 
posteriorly  it  gives  a  thin  covering  to  the  pyri- 
formis muscle.  (2)  The  visceral  layer  comes  off 
from  the  parietal  along  a  ligamentous  strand  run- 
ning from  the  lower  part  of  the  symphysis  pubis 
to  the  ischial  spine  and  known  as  the  white  line. 
The  bladder,  prostate,  and  vagina  are  supported 
from  the  white  line  by  the  visceral  layer  of  the  fascia. 

Starting  from  this  line  the  visceral  layer  passes 
down  into  the  pelvis  on  the  abdominal  surface  of 
the  levator  ani,  and  attaches  itself  to  all  the  pelvic 


Chap.  XVIII]       PELVIS    AND    PERINEUM  431 

viscera  with  which  it  comes  in  contact,  forming 
fibrous  expansions  or  "  ligaments/'  that  serve  to 
hold  the  viscera  in  place.  Were  there  no  pelvic 
viscera,  this  layer  of  the  fascia  would  be  con- 
tinued evenly  across  the  pelvic  floor  from  one  side 
to  the  other,  just  as  the  subperitoneal  fascia  is 
continued  over  the  under  surface  of  the  dia- 
phragm. Having  given  "  reflections  ,;  to  the 
pelvic  organs  the  visceral  layer  passes  on,  and, 
covering  the  opposite  levator  muscle,  ends  at  the 
opposite  white  line.  This  visceral  layer  is  usually 
known  as  the   recto-vesical   fascia. 

As  regards  the  parietal  division,  it  will  be 
seen  that  that  part  of  it  above  the  origin  of  the 
visceral  layer  (i.e.  above  the  white  line)  is  in  the 
pelvic  cavity,  while  that  part  below  the  line  is 
in  the  perineum.  To  this  lower  segment  the  name 
obturator  fascia  is  commonly  given.  Now,  the 
peritoneum  lines  some  part  of  the  pelvic  floor,  and 
covers  a  great  part  of  the  pelvic  viscera.  Be- 
tween this  peritoneum  and  the  visceral  layer  of 
the  pelvic  fascia  is  a  good  deal  of  loose  connec- 
tive tissue.  Inflammation  may  be  set  up  in  this 
tissue,  may  spread  readily  in  it,  and  may  of 
course  lead  to  suppuration.  Such  suppuration 
will  be  limited  to  the  pelvic  cavity,  and  will  be 
hindered  from  escaping  from  that  cavity  by  the 
pelvic  fascia.  Inflammations  of  any  extent  so 
located^  are  included  under  the  term  pelvic 
cellulitis.  Suppuration,  therefore,  above  the 
visceral  layer  of  the  pelvic  fascia  will  be 
limited  to  the  pelvic  cavity,  while  that  below 
this  layer  will  be  limited  to  the  perineum, 
to  either  the  urethral  or  the  anal  segment 
of  that  _  district.  _  Thus  it  will  be  seen  that 
the  pelvic  fascia  is  of  much  surgical  importance. 
Wounds  through  the  perineum  that  involve  this 
fascia  will_  be  serious,  in  that  they  will  open  up 
the  loose  tissue  on  the  pelvic  aspect  of  the  fascia 
in  which  inflammation  so  readily  spreads,  while 
unless  the  fascia  be  wounded  the  pelvic  cavity 
cannot  be  said  to  have  been  opened. 


432  SURGICAL   APPLIED   ANATOMY    [Part  IV 

The  fascia  is  so  reflected  upon  the  viscera  that 
certain  parts  of  them  are  excluded  by  the  attach- 
ments of  the  membrane   from  the   pelvic  cavity. 
The  parts  so  excluded  are  the  prostate  in  the  male 
and  part  of  the  vagina  in  the  female.     Over  that 
part  of  the  pelvic  floor  occupied  by  the  rectum 
and  over  the  rectum  itself  the  pelvic  fascia  is  so 
thin   as  scarcely  to  be   distinguishable   from  the 
subperitoneal  and  loose  pelvic  tissue  surrounding 
it.     The   rectum   is   loosely   embedded,    so   that  it 
may  the  more  easily  expand  and  contract;  indeed, 
the  only  part  which  is  at  all  firmly  attached  is  the 
anal    canal,    which   is    fixed    in    the    pelvic   floor. 
Pelvic    cellulitis,    to    use   the   term   in   the    strict 
sense,  means  inflammation  of  the  connective  tissue 
between   the   pelvic ,  fascia   and   the   peritoneum.* 
This  connective  tissue  is  chiefly  situated  between 
the  anterior  wall  of  the  bladder  and  the  pelvis, 
about  the  base  and  neck  of  the  bladder,  between 
the    latter    viscus    and   the    rectum;    and    in    the 
female,  between  the  layers  of  the  broad  ligament 
and  about  the  lower  part  of  the  uterus  and  com- 
mencement   of    the    vagina.     All    this    connective 
tissue  is  continuous,  and  inflammation  in  one  part 
of  it  may  spread  to  the  other  parts.     In  women 
the  mischief  is  often  found  between  the  folds  of 
the  broad  ligament,  or  in  the  hollow  between  the 
uterus  and  the  rectum.     As  may  be  supposed,  the 
abscess  formed  in  such  cases  tends  to  mount  up  in 
the    pelvis,    being    unable    to    escape   below,    and 
usually  points  in  the  inguinal  region,  or  in  the 
suprapubic     region,     having     spread     along    the 
obliterated   hypogastric   artery    (see  p.    330).      It 
may,  however,  open  into  one  of  the  pelvic  viscera 
or  into  the  peritoneum,   but  both  these  termina- 
tions are  rare.     Out  of  thirty-seven  cases  of  puer- 
peral pelvic  cellulitis  with  suppuration,  twenty- 
four  burst  externally,  and  for  the  most  part  in  the 
inguinal  region   (McClintock). 

*  Clinically  the  term  pelvic  cellulitis  includes  also  pelvic  peritonitis, 
and  often  inflammation  of  one  or  other  of  the  viscera.  Indeed,  many- 
so-called  oases  of  pelvic  cellulitis  are  examples  of  localised  pelvic 
peritonitis  with  or  without  suppuration. 


Chap.  XVIII]       PELVIS    AND    PERINEUM  433 

It  should  be  borne  in  mind  that  the  blood- 
vessels of  the  pur  is  are  placed  on  the  peritoneal 
aspect  of  the  fascia.  The  branches  of  the  internal 
iliac  artery,  therefore,  that  leave  the  pelvis,  escape 
by  piercing  that  membrane.  The  obturator  artery 
is  an  exception  to  this  rule,  since  it  passes  over 
the  upper  border  of  the  parietal  pelvic  fascia 
(Cunningham).  The  nerves  in  the  pelvis  lie  be 
hind  or  outside  the  fascia,  and,  therefore,  the 
pelvic  vessels  and  the  pelvic  nerves  are,  excepting 
the  obturator,  separated  from  one  another  by  this 
layer   of  tissue. 

The  male  perineum. — The  perineum  is  a 
lozenge-shaped  space  bounded  by  the  symphysis, 
the  rami  of  the  pubes  and  the  ischia,  the  ischial 
tuberosities,  the  great  sacro-sciatic  ligaments,  the 
edges  of  the  two  great  gluteal  muscles,  and  the 
coccyx.  A  transverse  line  drawn  across  the  space 
between  the  anterior  extremities  of  the  tubera 
ischii,  and  just  in  front  of  the  anus,  divides  the 
perineum  into  two  parts.  The  anterior  part 
forms  nearly  an  equilateral  triangle,  measuring 
about  3^  inches  on  all  sides.  It  is  called  the 
urethral  triangle.  The  posterior  part  is  also 
somewhat  triangular,  contains  the  rectum  and 
ischio-rectal  fossse,  and  is  called  the  anal  triangle. 
The  whole  space  measures  about  o\  inches  from 
side  to  side,  and  about  4  inches  from  before  back- 
wards in  the  middle  line.  The  average  antero- 
posterior diameter  of  the  pelvic  outlet  in  the  male 
averages  3^  inches.  This  measurement  in  the  un- 
dissected  subject  is  increased  to  4  inches  by  the 
curving  of  the  surface.  The  average  transverse 
diameter  of  the  male  pelvic  outlet  is  3i  inches, 
and  corresponds  to  the  measurement  of  the  perin- 
eum above  given. 

The  bony  framework  of  the  perineum  can  be 
felt  more  or  less  distinctly  all  round,  and  in  thin 
subjects  the  great  sacro-sciatic  ligaments  can  be 
made  out  beneath  the  great  gluteal  muscle.  The 
anus  is  in  the  middle  line  between  the  tubera 
ischii,  its  centre  being  about  lh  inches  from  the  tip 
2  C 


434 


SUEGICAL   APPLIED    ANATOMY    [Part  IV 


of  the  coccyx.  The  raphe,  a  central  mark  or 
ridge  in  the  skin,  can  be  followed  from  the  anus 
along  the  middle  line  of  the  perineum,  scrotum, 


Fig.  11.— The  male  perineum.    (After  Rudinger.) 


a,  Gluteus  niaximus:  b,  semi-tendinosus  and  biceps;  c,  adductor  magnus ; 
d,  gracilis  ;  e,  pyritormis  ;  /,  obturator  interims  ;  <j,  quadratus  femoris ;  h,  lev- 
ator ani ;  i,  external  sphincter ;  j,  accelerator  urinsB ;  k,  erector  penis ; 
I,  transversus  perinei ;  1,  great  sciatic  nerve  ;  2,  external  liannorrhoidal  vessels 
and  nerve  ;  3,  superficial  perineal  vessels  and  nerves  ;  4,  pudic  nerve  (cut) 
and  pudic  artery;  5,  pudendal  branch  <>f  small  sciatic  nerve. 

and  penis.  No  vessels  cross  this  line,  and,  there- 
fore, in  making  incisions  into  the  perineum  this 
line  is  always  chosen  when  possible.  In  the  middle 
line,  midway  between  the  centre  of  the  anus  and 
the  spot  where  the  scrotum  joins  the  perineum,  is 


Chap.  XVIII]       PELVIS    AND    PEEINEUM  435 

the  central  point  of  the  perineum.  The  two  trans- 
verse perineal  muscles,  the  accelerator  urinse  and 
the  sphincter  ani,  meet  at  this  point,  which  also 
corresponds  to  the  centre  of  the  inferior  edge  of 
the  triangular  ligament.  The  bulb  is  just  in 
front  of  it,  as  is  also  the  artery  to  the  bulb,  and 
in  lithotomy,  therefore,  the  incision  should  never 
commence  in  front  of  this  spot. 

The  perineal  space  is  separated  from  the  pelvic 
cavity  by  the  levator  ani  muscles  and  recto-vesical 
fascia,  as  already  mentioned.  The  depth  of  the 
perineum  means  the  distance  between  the  skin  and 
the  pelvic  floor.  This  depth  depends,  to  a  great 
extent,  upon  the  amount  of  fat  under  the  integu- 
ment. It  varies  considerably  in  different  parts, 
measuring  from  2  to  3  inches  in  the  hinder  and 
outer  parts  of  the  perineum,  and  less  than  1  inch 
in  the  anterior  parts  of  the  space. 

The  ischio-rectal  fossa  is  of  pyramidal 
shape,  its  apex  being  at  the  white  line,  and  its 
base  being  formed  by  the  skin  between  the  anus 
and  the  ischial  tuberosity.  It  measures  about  2 
inches  from  before  back,  1  inch  from  side  to  side, 
and  is  between  2  and  3  inches  in  depth.  Its 
boundaries  are  :  on  the  outer  side,  the  obturator 
internus  muscle,  covered  by  the  obturator  layer  of 
the  pelvic  fascia ;  on  the  inner  side,  the  levator 
ani,  covered  by  the  anal  fascia;  in  front,  the  base 
of  the  triangular  ligament  and  the  transversus 
perinei  muscle;  and  behind,  the  gluteus  maximus, 
great  sacro-sciatic  ligament,  and  coccygeus.  The 
pudic  vessels  and  nerves  are  on  the  outer  wall, 
embedded  in  the  fascia  over  the  obturator  muscle, 
and  are  placed  about  \\  inch  above  the  lower 
border  of  the  tuber  ischii. 

The  part  of  the  rectum  which  occupies  the 
space  between  the  two  fossae  is  supported  by  the 
levatores  ani,  external  sphincter,  and  recto-vesical 
fascia.  Its  lateral  wall  is  exposed  for  a  distance 
of _  nearly  3  _  inches,  its  posterior  wall  for  about 
1  inch  (Quain).  The  fossa  is  occupied  by  a  mass 
of  fat  which  affords  to  the  rectum  the  support  of 


436  SUKGICAL   APPLIED    ANATOMY    [Part  IV 

an  elastic  cushion.  This  fatty  tissue  is  badly 
supplied  with  blood,  and  this  fact,  in  addition 
to  the  dependent  situation  of  the  part,  and  its 
exposure  when  the  patient  sits  upon  damp,  cold 
seats,  etc.,  leads  to  abscess  being  very  frequent 
in  the  space  (ischio-rectal  abscess).  These  ab- 
scesses are  hemmed  in  on  all  sides,  soon  fill  the 
fossa,  and  then  tend  to  discharge  themselves  in 
the  two  directions  where  the  resistance  is  least, 
viz.,  through  the  skin  and  through  the  wall  of  the 
rectum.  When  this  double  discharge  of  the  ab- 
scess has  taken  place,  a  complete  fistula  in  ano  is 
established.  It  is  well  to  note  that  in  all  fistulce 
in  ano  the  opening  into  the  rectum  is  nearly 
always  within  \  an  inch  of  the  anus.  An  opening 
into  the  bowel  higher  up  is  resisted  by  the  attach- 
ment of  the  levatores  ani,  by  the  anal  fascia,  and 
by  the  recto-vesical  fascia. 

Crossing  the  space  obliquely  from  its  hinder 
part  to  the  anus  are  the  external  hsemorrhoidal 
vessels  and  nerves  (Fig.  71);  crossing  the  an- 
terior and  outer  corner  of  the  fossa  are  the 
perineal  vessels  and  nerves,  and  about  the  pos- 
terior border  of  the  space  are  the  fourth  sacral 
nerve  and  some  branches  of  the  small  sciatic  nerve. 
It  will  be  readily  understood,  therefore,  that 
ischio-rectal  abscesses  are  associated  usually  with 
extreme  suffering  until  they  are  relieved.  The 
most  severe  pain  is  probably  due  to  the  stretching 
of  the  external  hsemorrhoidal  nerve  by  the  abscess 
as  it  progresses  towards  the  surface.  In  opening 
an  abscess  in  the  fossa  the  main  structures  to 
avoid  are  the  rectum,  the  pudic  and  external 
hsemorrhoidal  vessels. 

Anns. — (See  p.  474.) 

The  urethral  triangle. — The  skin  of  the  peri- 
neum between  the  anus  and  the  scrotum  is  thin, 
and  shows  very  readily  any  extravasations  of 
blood  that  may  form  beneath  it.  The  superficial 
fascia  is  divided  into  two  layers,  of  which  the 
more  superficial  is  quite  unimportant,  and  con- 
tains what  little  subcutaneous  fat  exists  in  this  part, 


Chap.  XVIII]       PELVIS    AND    PERINEUM  437 

The  deep  layer,  known  as  the  perineal  fascia  or 
fascia  of  Colles,  is  attached  on  either  side  to  the 
rami  of  the  pubes  and  ischium,  and  behind  to  the 
base  of  the  triangular  ligament.  In  front  it  be- 
comes continuous  with  the  dartos  tissue.  This 
fascia,  therefore,  by  its  attachments  forms  with 
the  triangular  ligament  a  well-isolated  aponeu- 
rotic space,  containing  the  bulb  with  all  that  part 
of  the  spongy  urethra  between  the  triangular 
ligament  and  the  attachment  of  the  scrotum,  the 
penile  muscles,  the  transverse  perineal  muscles, 
vessels,  and  nerves,  and  the  perineal  vessels  and 
nerves.  When  extravasation  of  urine  follows 
upon  a  rupture  of  tne  part  of  the  urethra  above 
named,  the  course  of  the  escaping  fluid  is  directed 
by  the  fascia  of  Colles.  It  fills  the  aponeurotic 
space.  It  is  unable  to  gain  the  ischio-rectal  fossa 
on  account  of  the  attachment  of  the  fascia  to  the 
triangular  ligament.  The  lateral  attachments  of 
this  membrane  prevent  the  urine  from  passing 
into  the  thighs.  It  is  therefore  guided  into  the 
scrotum,  and  there  finds  itself  beneath  the  dartos 
tissue.  It  distends  the  scrotal  tissues,  and  then 
mounts  up  on  to  the  abdomen  through  the  gap 
left  between  the  symphysis  pubis  and  pubic  spine. 
It  must  be  remembered  that  the  fascia  of  Colles, 
the  dartos  tissue,  and  the  deeper  layer  of  the 
superficial  fascia  of  the  abdomen,  are  continuous, 
and  merely  represent  different  parts  of  the  same 
structure.  Pus  or  blood  within  this  aponeurotic 
space  would  follow  the  same  course  if  the  effusion 
were  extensive  enough.  The  pain  occasioned  by 
such  effusion  can  be  understood  when  it  is  noted 
that  the  three  chief  sensory  nerves  of  this  region 
(the  three  long  scrotal  nerves)  are  included  within 
the  space. 

The  triangular  ligament  has  a  depth  of 
about  1^  inch  in  the  middle  line,  and  is  formed 
of  two  layers,  of  which  the  posterior  is  derived 
from  the  pelvic  fascia.  The  membranous  urethra, 
surrounded  by  the  compressor  urethrse,  lies  be- 
tween the  two  layers,  and  runs  about  1  inch  below 


438  SUBGICAL    APPLIED    ANATOMY    [Part  IV 

the  symphysis,  and  about  f  of  an  inch  above  the 
central  point  of  the  perineum  (Fig.  72).  The 
artery  to  the  bulb  passes  inwards  between  the  two 
layers  about  \  an  inch  above  the  base  of  the 
ligament  and  \\  inch  in  front  of  the  anus.  The 
dorsal  vein  and  the  terminal  part  of  the  pudic 
artery  and  nerve  pierce  the  anterior  layer  of  the 
ligament  about  \  an  inch  below  the  symphysis. 
In  uncomplicated  rupture  of  the  membranous 
urethra,  the  urine  extravasated  would  be  limited 
to  the  space  between  the  layers  of  the  ligament, 
until  subsequent  suppuration  had  made  a  way 
for  it  to  escape.  When  extravasation  occurs  be- 
hind the  triangular  ligament,  the  effusion  may 
collect  in  the  retropubic  space  if  the  pelvic  fascia 
is  ruptured  (Deanesley),  or  it  may  pass  back- 
wards by  the  side  of  the  rectum  into  the  cellular 
tissue  of  the  pelvis. 

Just  beyond  the  triangular  ligament  is  the 
prostate,  surrounded  by  its  capsule,  and  the  pros- 
tatic venous  plexus  (Fig.  72).  In  dissecting  down 
from  the  surface  to  the  prostate,  we  meet,  as 
Cunningham  has  well  pointed  out,  alternate  strata 
of  fascial  and  muscular  tissue,  forming  seven 
layers  in  all,  viz.  (1)  superficial  fascia;  (2)  super- 
ficial perineal  muscles;  (3)  triangular  ligament 
(ant.  layer) ;  (4)  compressor  urethras  muscle;  (5) 
triangular  ligament  (post,  layer)  ;  (6)  levator  ani 
muscle;  (7)  sheath  of  prostate. 

Stone  in  the  bladder. — Stones  of  the  bladder 
which  were  formerly  removed  by  a  perineal  in- 
cision are  now  commonly  crushed  and  washed  out 
through  the  urethra  by  the  operation  of  litho- 
lapaxy.  This  operation  is  carried  out  readily 
even  in  male  children.  If  the  stones  are  too 
large  for  crushing,  the  supra-pubic  operation  is 
performed  to  give  sufficient  room  for  extraction. 
Although  the  perineal  operations  are  now  but  very 
rarely  performed^  a  description  of  the  parts  in- 
volved helps  to  give  a  proper  conception  of  their 
important  anatomical  relationships. 

Lateral     lithotomy. — The  first  incision,  2  or 


Chap.  XVIII]      PELVIS    AND    PERINEUM 


43d 


Fig.  72. — A  vertical  anteroposterior  section  of  the  male  pel  is 
(Braune). 


440  SURGICAL    APPLIED    ANATOMY    [Part  IV 

3  inches  in  length,  is  commenced  just  to  the  left 
of  the  middle  line  and  just  behind  the  central 
point  of  the  perineum,  i.e.  about  l\  inch  in 
front  of  the  anus.  The  incision  is  carried  down- 
wards and  outwards  into  the  left  ischio-rectal 
fossa,  and  ends  at  a  point  between  the  tuber  ischii 
and  posterior  part  of  the  anus,  and  one-third 
nearer  to  the  tuberosity  than  to  the  gut.  In  the 
early  part  of  this  incision  the  staff  may  just  be 
touched,  as  it  lies  in  the  membranous  urethra,  the 
incision  becoming  more  and  more  shallow  as  the 
knife  is  withdrawn.  The  parts  cut  in  the  first 
incision    are:     (1)    skin    and    superficial    fascia; 

(2)  transverse  perineal  muscle,  artery  and  nerve ; 

(3)  the  lower  edge  of  the  anterior  layer  of  the 
triangular  ligament;  (4)  the  external  hsemor- 
rhoidal  vessel  and  nerves  (Figs.  71  and  72). 

In  the  second  incision  the  knife,  guided  by  the 
fore-finger  of  the  left  hand,  is  passed  upwards 
behind  the  triangular  ligament,  is  engaged  in  the 
groove  on  the  staff  as  it  lies  in  the  membranous 
urethra,  and  then,  having  its  edge  turned  towards 
the  left  tuber  ischii,  is  steadily  carried  along 
the  groove  into  the  bladder.  In  this  incision  the 
parts  divided  are  :  (1)  membranous  and  prostatic 
portions  of  urethra;  (2)  posterior  layer  of  tri- 
angular ligament;  (3)  compressor  urethrse;  (4) 
anterior  fibres  of  levator  ani  and  left  lateral  lobe 
of  prostate.  The  finger  is  then  introduced  along 
the  staff  into  the  bladder,  the  staff  is  removed, 
and,  the  forceps  being  inserted,  the  stone  is  ex- 
tracted, traction  being  made  in  the  proper  axis 
of  the  pelvis. 

Parts  that  may  be  wounded. — (a)  In  the  first 
incision  :  (1)  the  bulb,  or  the  artery  of  the  bulb. 
These  parts  can  be  avoided  by  commencing  the 
incision  well  behind  the  "  central  point/'  and  by 
causing  the  holder  of  the  staff  to  draw  it,  the 
scrotum,  and  the  penis  well  up.  The  staff  should 
be  held  as  close  up  under  the  pubes  as  possible. 
The  bulb  is  very  small  in  children,  large  in 
adults,   and  largest  in  old  men.     (2)  The  rectum 


Chap.  XVIII.     PELVIS    AND    PERINEUM  441 

may  be  cut  if  much  distended,  or  if  the  incision 
be  made  too  vertical  or  carried  too  far  back.  In 
all  cases  the  gut  should  be  well  emptied  by  enema 
before  the  operation.  (3)  The  pudic  vessels  can 
hardly  be  wounded  unless  the  incision  is  very 
carelessly  made,  and  the  knife  carried  almost 
against  the  bone  as  it  is  being  withdrawn,  (b) 
In  the  second  incision  the  knife  may  be  passed 
beyond  the  prostate,  and  may  so  incise  the  vis- 
ceral layer  of  the  pelvic  fascia  as  to  open  up  the 
pelvic  cavity.  It  will  be  understood  that  the 
lateral  lobe  of  the  prostate  may  be  cut  freely 
without  this  cavity  being  endangered.  The  gland 
is  enveloped  by  the  pelvic  fascia,  but  the  incision 
made  into  the  prostate  is  well  below  the  superior 
reflection  of  the  membrane.  The  incision  in  the 
neck  of  the  bladder,  therefore,  must  be  strictly 
limited  to  the  prostate.  The  prostatic  plexus  of 
veins  cannot  avoid  being  wounded.  The  left 
ejaculatory  duct  would  be  cut  if  the  prostatic 
incision  were  carried  too  far  backwards. 

In  children  the  pelvis  is  relatively  narrower 
than  in  the  adult,  the  bladder  is  more  an  ab- 
dominal than  a  pelvic  organ,  and  the  neck  of  the 
bladder,  therefore,  is  high  up.  The  viscus,  more- 
over, is  very  movable,  and  has  less  substantial 
attachments  than  has  the  adult's  bladder.  It  thus 
happens  that  in  forcing  the  finger  into  the  bladder 
after  the  second  incision,  the  viscus  has  actually 
been  torn  away  from  the  urethra.  In  children 
the  prostate  is  rudimentary,  and  thus  more  of 
the  actual  neck  of  the  bladder  itself  has  to  be 
cut.  From  the  small  size  of  this  gland,  it  hap- 
pens, too,  that  in  some  cases  the  knife  has  passed 
too  far  beyond  the  prostatic  area,  and  has  opened 
up  the  pelvic  fascia.  In  children  also  the  peri- 
toneum descends  lower  on  the  posterior  surface 
of  the  bladder,  and  may  be  wounded  by  a  careless 
operator. 

.Median  lithotomy.  —  In  this  operation  the 
knife  is  entered  in  the  middle  line,  just  in  front 
of  the  anus.     The  staff  has  a  central  groove,  and 


442  SUEGICAL    APPLIED    ANATOMY    [Part  IV 

the  point  of  the  knife  should  hit  the  instrument 
as  near  as  possible  to  the  apex  of  the  prostate. 
As  the  knife  is  withdrawn  the  whole  of  the  mem- 
branous urethra  is  incised,  and  a  wound  made 
in  the  median  raphe  of  about  \\  inch  in  length. 
The  incision  is  made  by  cutting  upwards.  i\ 
probe  is  then  introduced  into  the  bladder,  and, 
the  staff  being  removed,  the  finger  is  passed  into 
that  viscus  by  steady  dilatation  of  the  parts,  with 
some  laceration  of  the  prostate.  The  object  in 
this  operation  is  to  enter  the  bladder  with  the 
least  amount  of  cutting,  and  by  dilatation  rather 
than  incision. 

Farts  divided. — (l)  Skin  and  superficial 
fascia ;  (2)  sphincter  ani ;  (3)  central  point  of 
perineum ;  (4)  lower  border  of  triangular  liga- 
ment; (5)  whole  length  of  membranous  urethra; 
(6)   compressor  urethrse. 

Advantages. — (1)  The  bleeding  is  much  less 
than  in  the  lateral  operation,  the  slight  vascu- 
larity of  the  raphe  being  well  known.  (2)  The 
pelvic  fascia  is  much  less  likely  to  be  wounded 
if  the  bladder  be  entered  by  dilation  rather  than 
by   incision,    as   in   the   lateral   procedure. 

Disadvantages. — (1)  The  bulb  is  in  great  risk 
of  being  wounded.  It  must,  however,  be  noted 
that  wounds  of  the  bulb  in  the  middle  line  do  not 
bleed  readily,  as  a  rule.  (2)  The  amount  of  space 
obtained  for  the  removal  of  the  stone  is  very 
slight.  (3)  In  children  the  operation  in  its  in- 
tegrity is  scarcely  possible,  since  the  prostate  is 
quite  rudimentary,  and  the  slight  attachments 
of  the  parts  are  such  that,  in  using  forcible  dila- 
tation, the  bladder  may  readily  be  torn  from  the 
urethra.  If  the  incision  be  made  upwards,  and 
one  linger  be  retained  in  the  rectum,  the  risk  of 
wounding  the   gut  is  not  great. 

In  lithotomy,  and  in  other  operations  for  reach- 
ing the  neck  of  the  bladder  through  the  perineum, 
it  should  be  remembered  that  the  bladder  lies  at 
a  depth  of  from  2|  to  3  inches  from  the  surface 
when  the  body  is  in  the  lithotomy  position  (Fig.  72). 


Chap.  XVIII]       PELVIS    AND    PERINEUM  443 

If  the  bladder  is  empty  and  the  rectum  full, 
the  prostate,  trigone  and  reflection  of  peritoneum 
are  carried  upwards  and  forwards;  if  the  bladder 
is  full  and  the  rectum  empty,  the  movement  is  in 
an  opposite  direction ;  in  fat  people  the  bladder 
and  peritoneum  are  carried  away  from  the 
perineum. 

Suprapubic  litliotoiny. — This  operation  has 
been  revived  of  late  years,  and  in  cases  in  which 
litholapaxy  is  contraindicated  has  practically 
supplanted  the  two  forms  of  lithotomy  just  de- 
scribed. In  order  to  bring  the  summit  of  the 
bladder  well  above  the  symphysis,  both  bladder 
and  rectum  may  be  dilated.  Into  the  former  vis- 
cus,  tepid  water  or  bora^ic  lotion  is  injected.  It 
is  found  that  in  the  adult  8  to  10  ounces  is  suffi- 
cient to  ensure  the  desired  distension.  The  rectum 
is  dilated  by  some  operators  by  means  of  a  soft 
rubber  bag.  The  gut,  when  thus  distended, 
pushes  forward  the  bladder,  and  gives  it  a  firm 
basis  upon  which  to  rest.  In  the  adult  from  10 
to  14  ounces  are  usually  introduced  into  the  bag. 
Distension  of  the  rectum  alone  will  elevate  the 
bladder,  but  may  have  no  effect  upon  the  reflection 
of  peritoneum.  In  operating  upon  children  the 
rectal  bag  is  very  seldom  required,  and  many 
surgeons  do  not  employ  it  in  any  case.  In  the 
case  of  a  male  child,  aged  five,  the  injection  of 
3  ounces  of  water  into  the  bladder  caused  the 
reflection  of  peritoneum  to  mount  to  more  than 
1  inch  above  the  symphysis.  An  incision,  some  3 
inches  in  length,  is  made  immediately  above  the 
symphysis  in  the  median  line.  The  bladder  is 
exposed  below  the  peritoneum,  is  drawn  forwards 
by  a  hook,   and  opened. 

The  bladder.  —  When  empty  the  bladder  is 
flattened  and  of  triangular  outline,  and  lies 
against  the  anterior  wall  of  the  pelvis.  The 
empty  bladder  may  be  found  in  one  of  two  condi- 
tions (as  demonstrated  by  Dr.  Hart  in  the  adult 
female  bladder).  It  may  be  small,  oval,  and 
firm,    with    its    upper    wall    convex    towards    the 


444  SURGICAL   APPLIED    ANATOMY    [Part  IV 

abdomen.  In  vertical  anteroposterior  section  the 
urethra  forms  with  the  cavity  of  the  bladder  a 
curved  slit  (the  systolic  empty  bladder).  It  may 
be  larger,  and  soft,  with  its  upper  surface  con- 
cave towards  the  abdomen,  and  fitting  into  the 
concavity  of  the  lower  wall  or  surface.  In  the 
section  named,  the  urethra  forms,  with  the  blad- 
der cavity,  a  Y-shaped  figure,  the  two  diverging 
limbs  of  the  Y  corresponding  to  the  concavity 
named  (the  diastolic  empty  bladder).  When 
moderately  distended  with  an  opaque  solution 
and  examined  by  the  aid  of  X-rays  it  is  seen  to 
be  conical  in  form,  with  its  apex  behind  the  sym- 
physis and  its  base  or  upper  surface  indented 
by  the  pressure  of  the  abdominal  viscera  (Fig.  70, 
p.  418).  As  distension  of  the  bladder  increases, 
the  summit  of  the  viscus  is  brought  more  and  more 
in  contact  with  the  anterior  abdominal  wall,  the 
organ  becoming  also  more  convex  on  its  posterior 
than  on  its  anterior  surface.  This  tendency  for 
the  summit  of  the  distended  bladder  to  press  itself 
against  the  anterior  parietes  is  of  good  service  in 
tapping  the  organ  above  the  pubes,  and  in  supra- 
pubic lithotomy.  When  greatly  distended  it  may 
reach  the  umbilicus,  and  may  even  touch  the  dia- 
phragm. The  usual  capacity  of  the  organ  is 
about  one  pint,  but  when  fully  occupied  it  may 
hold  some  quarts.  When  both  bladder  and  rec- 
tum are  quite  empty  the  apex  of  the  bladder  and 
the  prevesical  reflection  of  the  peritoneum  are  a 
little  below  the  upper  margin  of  the  symphysis 
pubis.  As  the  distended  bladder  ascends  above 
the  pubes  it  dissects  the  serous  membrane  from 
the  parietes,  and  the  layer  so  lifted  off  forms  a 
cul-de-sac  or  fold  of  peritoneum  between  the 
upper  part  of  the  anterior  surface  of  the  bladder 
and  the  parietes.  When  the  apex  of  the  bladder  is 
2  inches  above  the  pubes  the  peritoneal  reflection 
is  probably  not  more  than  f  of  an  inch  above 
the  same  point  of  bone.  When  the  apex  of  the 
bladder  is  midway  between  the  umbilicus  and  the 
pubes  there  may  be  2  inches  (vertical)  of  the  an- 


Chap.  XVIII]      PELVIS    AND    PERINEUM  445 

terior  abdominal  wall  in  the  middle  line  and  im- 
mediately above  the  symphysis  devoid  of  peri- 
toneal lining.  Thus  it  happens  that  the  distended 
viscus  may  be  readily  tapped  above  the  pubes 
without  the  peritoneum  being  wounded.  As  the 
bladder  becomes  distended,  not  only  does  it  rise 
into  the  abdomen,  but  it  extends  also  towards  the 
perineum,  diminishing  the  length  of  the  prostatic 
and  membranous  urethra.  In  suprapubic  litho- 
tomy that  tendency  to  extend  downwards  is  pre- 
vented by  the  rectal  bag  (p.  442). 

Between  the  anterior  surface  of  the  bladder 
and  the  symphysis,  and  shut  in  by  the  peritoneum 
above,  is  the  retropubic  or  prevesical  space,  con- 
taining lax  connective  tissue  (Fig.  73).  The  loose- 
ness of  this  connective  tissue  permits  the  bladder 
to  readily  ascend  as  it  fills.  In  injuries  to  the 
pelvis  and  to  the  front  of  the  bladder  a  diffuse 
inflammation  may  be  set  up  in  this  tissue  and 
assume  serious  proportions.  I  have  reported  a 
case  where  an  extensive  suppuration  in  this  area 
followed  upon  aspiration  of  the  bladder  above 
the  pubes,  and  led  to  death.  Like  suppuration 
has  followed  suprapubic  lithotomy.  In  rupture 
of  the  anterior  wall  of  the  viscus  or  of  the  urethra 
above  the  triangular  ligament  the  urine  escapes 
into  this  district  of  cellular  tissue ;  a  limited  sup- 
puration may  follow  and  recovery  ensue. 

The  bladder,  although  fairly  fixed,  has  been 
found  in  inguinal,  femoral,  and  vaginal  hernise. 
In  the  erect  position  its  neck  (in  the  male)  lies 
on  a  horizontal  line  drawn  from  before  backwards 
through  a  point  a  little  below  the  middle  of  the 
symphysis,  and  is  placed  about  1\  inch  (3  cm.) 
behind   that   articulation    (Tillaux). 

Relations  to  the  peritoneum. — The  anterior 
surface  is  entirely  devoid  of  peritoneum,  while 
the  superior  surface  is  entirely  covered  by  that 
membrane.  At  the  sides  there  is  no  peritoneum 
in  front  of,  or  below,  the  obliterated  hypogastric 
arteries.  On  the  posterior  aspect  of  the  bladder 
the  serous  membrane  extends   down  as  far   as  a 


446  SUKGICAL   APPLIED    ANATOMY    [Part  IV 

transverse  line,  uniting  the  upper  parts  of  the 
two  seminal  vesicles,  so  that  the  upper  ends  of 
the  vesicles  are  covered  by  peritoneum.  This 
recto-vesical  pouch  of  peritoneum  in  the  adult  ex- 
tends to  within  about  3  inches  of  the  anus,  and 
does  not  reach  below  a  line  1  inch  above  the  base 
of  the  prostate.  Harrison  Cripps  gives  the  dis- 
tance of  the  pouch  from  the  anus  as  2|  inches 
when  the  bladder  and  rectum  are  both  empty, 
and  as  3j  inches  when  those  viscera  are  distended. 
(See  Bladder  in  the  Child,  p.   450.) 

Puncture  of  the  bladder  per  rectum. — 
The  base  of  the  bladder  is  adherent  to  the  rectum 
by  dense  areolar  tissue  over  a  triangular  area 
the  apex  of  which  is  formed  by  the  prostate, 
the  sides  by  the  diverging  seminal  vesicles,  and 
the  base  by  the  recto-vesical  fold  of  peritoneum. 
This  triangle  is  equilateral,  and  in  the  dissected 
specimen  measures  about  l\  inch  on  all  sides. 
It  corresponds  to  the  trigone  on  the  inner  surface 
of  the  viscus.  It  is  through  this  triangle,  and 
as  near  as  possible  to  the  prostate,  that  the  blad- 
der is  tapped  when  the  operation  is  performed 
per  rectum.  The  recto-vesical  fold  of  peritoneum 
is  raised,  and  is  carried  still  farther  from  the 
anus  when   the   organ   is   distended. 

Rupture  of  bladder.— The  bladder  may  be 
ruptured  by  violence  applied  to  the  anterior  ab- 
dominal wall  apart  from  pelvic  fracture  or  ex- 
ternal evidence  of  injury.  Such  a  rupture  can, 
however,  hardly  happen  to  the  empty  bladder ; 
it  must  be  full  or  distended  at  the  time  of  the  acci- 
dent. It  is  very  rare  for  the  rupture  to  be  on  the 
anterior  surface  only.  As  a  rule,  the  tear  in- 
volves the  superior  or  abdominal  surface,  and  im- 
plicates the  peritoneum.  The  injury,  therefore, 
is  very  fatal  (five  recoveries  out  of  seventy-eight 
cases).  In  some  cases  of  vesical  rupture  the  sur- 
geon has  opened  the  abdomen  and  has  stitched  up 
the  rent  in  the  viscus  with  perfect  success.  The 
bladder  may  be  torn  by  fragments  of  bone  in 
fractures   of   the    pelvis,    or   by   violence    applied 


Chap.  XVIII]      PELYIS    AND    PERINEUM  447 

through  the  rectum  or  vagina.  A  case,  for  ex- 
ample, is  reported  (Holmes's  "  System  of  Sur- 
gery ")  of  a  man  who  fell  upon  a  pointed  stake 
fixed  in  the  earth.  The  stake  passed  through  the 
anus,  pierced  the  rectum,  and  entered  the  bladder 
near  the  prostate.  The  patient  recovered,  the 
wound  having  been  made  in  the  triangular  area 
on  the  fundus  of  the  bladder  alluded  to  above, 
and  therefore  outside  the  peritoneum.  The  viscus 
may  be  ruptured  by  an  accumulation  of  urine,  as 
seen  in  cases  of  congenital  closure  of  the  urethra 
in  some  infants.  In  the  museum  of  the  Royal 
College  of  Surgeons  is  a  preparation  of  "  the 
bladder  of  a  woman  which  burst  near  the  entrance 
of  the  ureter  in  consequence  of  neglected  reten- 
tion of  urine. ;;  In  neglected  cases  of  stricture  in 
the  male  the  urethra  gives  way  rather  than  the 
bladder,  and  an  extravasation  of  urine  into 
the  perineum  follows.  A  small  puncture  of  the 
bladder,  as,  for  example,  that  made  by  a  fine 
trochar,  is  at  once  closed  by  the  muscular  con- 
traction of  its  wall. 

The  mucous  meintoraiie  of  the  bladder  is 
very  lax,  to  allow  of  its  accommodating  itself  to 
the  varying  changes  in  the  size  of  the  viscus. 
Over  the  trigone,  however,  it  is  closely  adherent, 
and  were  it  not  so  the  loose  mucous  membrane 
would  be  constantly  so  prolapsed  into  the  urethral 
orifice  during  micturition  as  to  block  up  the  neck 
of  the  bladder.  When  examined  by  the  cystoscope, 
the  mucous  membrane  is  seen  to  be  red  and  con- 
gested when  the  bladder  is  empty,  pale  and 
ansemic  when  the  bladder  is  full  (Newman).  The 
trigone  is  bounded  by  three  orifices,  for  the  ure- 
thra and  the  two  ureters,  and  forms  an  equilateral 
triangle,  measuring  about  lh  inch  on  all  sides. 
It  is  here  that  the  effects  of  cystitis  are  most  evi- 
dent, and  the  unvielding  character  of  the  mucous 
membrane  over  the  trigone  serves  in  part  to  ex- 
plain the  severe  symptoms  that  follow  acute  in- 
flammation of  that  structure.  Since  the  orifice 
of  the  urethra  forms  the  lowest  part  of  the  bladder 


448  SUKGICAL   APPLIED    ANATOMY    [Part  IV 

in  the  erect  posture,  it  follows  that  calculi  gravi- 
tate towards  the  trigone,  and  are  very  apt  to 
irritate  that  part  of  the  interior.  The  same  re- 
mark applies  to  foreign  bodies  in  the  viscus.  The 
mucous  membrane  about  the  trigone  and  neck  is 
very  sensitive,  whereas  the  interior  of  the  re- 
mainder of  the  bladder  appears  to  be  singularly 
defective  in  common  sensation.  This  can  be  well 
noted  in  using  sounds  and  catheters. 

The  sensory  nerves  for  the  bladder  are  de- 
rived mainly  from  two  parts  of  the  spinal  cord, 
namely,  the  twelfth  dorsal  and  first  lumbar  seg- 
ments, and  the  second,  third,  and  fourth  sacral 
segments.  From  the  first  source  (through  the 
hypogastric  plexus)  come  the  sensory  nerves  to 
the  upper  part  of  the  bladder  and  the  motor 
nerves  which  stimulate  the  internal  sphincter  and 
inhibit  the  expelling  musculature ;  from'  the 
second  source  (through  the  nervi  erigentes)  the 
motor  fibres  which  stimulate  the  expelling  mus- 
culature and  inhibit  the  sphincter.  The  trigone, 
having  the  same  nerve  supply  as  the  penis  and 
scrotum,  gives  rise,  when  injured,  to  pains  which 
are   referred  along  the   perineal   nerves. 

In  the  muscular  coat  of  the  bladder  the 
fibres  are  collected  in  bundles  which  interlace  in 
all  directions.  When  the  viscus  becomes  hyper- 
trophied  these  bundles  are  rendered  very  distinct, 
and  produce  the  appearance  known  as  "  fascicu- 
lated bladder. "  This  simply  means  that  the 
muscle  of  the  bladder,  having  been  unduly  exer- 
cised to  overcome  some  obstruction  to  the  escape 
of  urine,  increases  in  size,  as  do  other  much- 
exercised  muscles,  and  that  increase  serves  to 
demonstrate  the  arrangement  of  the  individual 
bundles.  From  distension  the  mucous  membrane 
becomes  bulged  out  between  the  unyielding  muscle 
bundles,  so  that  sacculi  are  formed,  and  the  ap- 
pearance known  as  "  sacculated  bladder  "  is  pro- 
duced. In  some  cases  the  parietes  yield,  especially 
at  one  part,  and  one  large  saccule  is  produced. 
In  this  way  a  sacculus  may  be  formed  which  in 


Chap.  XVIII]       PELVIS    AND    PERINEUM  449 

time  may  become  almost  as  large  as  the  bladder 
itself,  and  give  rise  to  the  erroneus  description 
of  "  double  bladder,"  etc. 

The  ureters  run  for  f  of  an  inch  in  the  mus- 
cular wall  of  the  viscus,  and  their  oblique  course, 
together  with  the  action  of  the  muscular  _  tissue 
about  them,  tends  to  prevent  regurgitation  of 
urine.  On  cystoscopic  examination  it  is  seen  that 
once  or  twice  a  minute  each  ureter  contracts  and 
expels  a  spurt  of  urine  into  the  bladder ;  be- 
tween these  spurts  the  ureteric  orifices  are  closed 
as  if  by  a  sphincter.  If  the  ureter  becomes  con- 
tracted, as  is  the  case  if  it  is  the  seat  of  a  tuber- 
cular ulceration,  the  vesical  orifice  of  the  ureter 
is  pulled  outwards  (Fenwick).  The  mucous  mem- 
brane is  laxly  attached  and  may  be  prolapsed 
within  the  bladder  as  a  pedunculated  body.  In 
cases  of  retention  the  ureters  become  distended ; 
but  this  is  due  rather  to  accumulation  of  urine 
within  them  than  to  its  reflux  from  the  bladder. 
In  cases  of  great  distension  of  the  bladder  the 
neck  of  the  viscus  is  opened  up  by  the  pressure 
from  within,  and  the  patient  exhibits  the  feature 
of  overflow  of  urine. 

The  female  bladder  is  less  capacious  than 
that  of  the  male.  Its  neck  is  situate  a  trifle 
nearer  to  the  symphysis  than  it  is  in  the  male, 
and  lies  in  a  horizontal  line  continued  back  from 
the  lower  border  of  the  symphysis.  There  being 
no  prostate,  the  neck  of  the  bladder  is  very  dis- 
tensible, and  this  fact,  taken  in  connection  with 
the  shortness  and  dilatability  of  the  urethra, 
allows  of  most  stones  being  extracted  by  forceps 
without  cutting.  By  simple  dilatation,  stones  of 
a  diameter  of  f  of  an  inch  have  been  removed. 
Through  the  dilated  urethra  the  orifices  of  the 
ureters  can  be  seen  and  examined.  The  intimate 
relation  of  the  bladder  to  the  vagina  allows  it  to 
be  examined  well  from  the  latter  passage,  and 
the  comparative  thinness  of  the  dividing  wall 
serves  to  explain  the  frequency  of  vesico-vaginal 
fistulse.  Strange  foreign  bodies  have  been  intro- 
2  D 


450  SURGICAL   APPLIED    ANATOMY    [Part  IV 

duced  into  the  female  bladder,  such  as  hair-pins, 
crochet  hooks,  sealing-wax,  penholders,  and  the 
like. 

The  orifice  of  the  ureter  is  3  cm.  from  the  cervix 
uteri,  and  4  cm.  from  the  vesical  opening  of  the 
urethra.  Its  close  relation  to  the  cervix  renders 
it  liable  to  injury  in  supravaginal  amputation  of 
that  part,  and  in  certain  operations  on  the 
uterus. 

r*!  The  bladder  in  the  child  is  egg-shaped,  and 
its  vertical  axis  is  relatively  much  greater  than 
it  is  in  the  adult.  The  larger  end  of  the  egg- 
shaped  cavity  is  directed  downwards  and  back- 
wards. The  fundus  is  developed  and  the  pelvic 
position  assumed  about  the  fourth  year  (Birming- 
ham). The  viscus  is  situated  mainly  in  the  abdo- 
men, the  pelvis  being  small  and  very  shallow.  At 
birth  the  orifice  of  the  urethra  is  on  a  level  with 
the  upper  edge  of  the  symphysis.  Although  the 
bladder  projects  so  freely  into  the  abdomen,  its 
anterior  wall  is  still  entirely  uncovered  by  peri- 
toneum. On  the  posterior  wall  the  serous  mem- 
brane extends  lower  down  than  in  the  adult, 
reaching  the  level  of  the  urethral  orifice  at  the 
time  of  birth,  and  the  level  of  the  prostate  in 
young  male  children.  The  prostate  is  exceedingly 
small  in  children.  Thompson  states  that  at  the 
age  of  seven  years  it  only  weighs  thirty  grains, 
whereas  in  subjects  between  eighteen  and  twenty 
it  weighs  two  hundred  and  fifty  grains.  The 
bladder  wall  in  the  child  is  so  thin  that  in  sound- 
ing for  stone  it  is  said  that  a  "  click  ';  may  be 
elicited  by  striking  the  pelvis  through  the  parietes 
of  the  viscus. 

The  prostate. — The  prostate  is  situated  about 
I  of  an  inch  below  the  symphysis  pubis,  and  rests 
upon  the  rectum  above  the  anal  canal  (Fig.  72). 
It  is,  therefore,  placed  within  1^  to  2  inches  from 
the  anus,  and  can  be  readilv  examined  from  the 
bowel.  The  prostate  is  made  up  of  two  lateral 
lobes  which  fuse  together  in  front  of  the  urethra 
by  a  pubic  commissure   (Fig.   73)   and  behind  by 


Chap.  XVIII)       PELVIS    AND    PERINEUM 


451 


two  commissures,  one  above  the  common  ejacula- 
tory  ducts — the  median  commissure — and  one  be- 
low these  ducts — the  rectal  commissure  {see  Fig. 
73,  b,  d).  The  part  here  named  median  commis- 
sure was  formerly  known  as  the  median  lobe — a 
name  which  is  apt  to  mislead,  for  it  is  not  a 
separate  lobe,  but,  as  already  explained,  merely 
a   fusion   of   the   two   lateral   lobes.     Each   gland 


Fig.  73.— A,  Median  section  of  the  normal  prostate  ;  B,  similar  section 
of  enlarged  prostate. 

a, a,  Sphincter  vesicae;  b,  median  commissure;  c,  common  ejactulatory  duct ;  d, 
rectol  commissure  ;  e,e,  constrictor  urethras  ;  v,  rectOr-urethral  muscle  ;  u,  Cow- 
per's  gland  ;  n,  ejaculator  urinae  ;  I,  internal  sphincter  of  anus ;  .t,  external. 
sphincter  of  anus  ;  k,  symphysis  pubis  ;  L,  retropubic  space  ;  m,  pubo- 
prostatic ligaments  and  sheath  of  prostate  ;  N,  dorsal  vein  of  penis  ;  o,  pubic 
commissure  ;  p,  corpus  cavernosum  ;  q,  urethra  ;  r,  bulb. 


is  made  up  of  numerous  branching  tubular  glands 
which  are  embedded  in  and  surrounded  by  non- 
striated  muscle  and  fibrous  tissue.  The  glands 
end  in  the  urethra — chiefly  in  the  prostatic 
sinuses — but  the  use  of  their  secretion  is  un- 
known. 

The  secretion  from  the  gland  is  discharged 
through  the  long  and  very  narrow  ducts  of  glands 
which  are  diffusely  arranged  as  two  lateral  masses 
or  lobes.  In  certain  forms  of  prostatic  irrita- 
tion, little  white  opaque  threads,  very  much  like 


452  SURGICAL   APPLIED    ANATOMY    [Part  IV 

short  pieces  of  cotton,  are  found  in  the  urine, 
and  are  actual  casts  of  the  prostatic  ducts. 

The  sheath  and  capsule  of  the  prostate. — 

Owing  to  the  success  which  has  attended  enuclea- 
tion as  a  means  of  treatment  for  enlarged  pros- 
tate, much  discussion  has  recently  taken  place 
concerning  its  ensheathing  structures.  The  term 
capsule  is  now  usually  applied  to  the  superficial 
fibro-muscular  stratum  of  the  gland,  while  the 
term  sheath  is  applied  to  the  enveloping  fibrous 
structure  derived  from  the  pelvic  fascia.  In  enu- 
cleating the  gland  everything  within  the  sheath 
is  removed.  At  only  one  part  is  the  sheath  in- 
timately adherent  to  the  capsule,  and  that  is 
along  the  anterior  or  pubic  surface ;  elsewhere 
it  is  free  from  it.  Since  the  base  of  the  prostate  is 
applied  to  the  bladder  and  uncovered  by  the 
sheath,  while  elsewhere  it  is  enclosed,  it  follows 
that  the  sheath  is  most  easily  entered  and  the 
gland  enucleated  from  the  bladder.  The  sheath 
determines  the  course  of  a  prostatic  abscess. 

The  prostatic  abscess  usually  bursts  into 
the  urethra,  that  being  the  direction  in  which 
least  resistance  is  encountered.  If  it  does  not 
enter  the  urethra,  it  will  probably  open  into  the 
rectum,  there  being  only  one  layer  of  the  pelvic 
fascia,  and  that  layer  not  a  thick  one,  between 
the  two  organs.  This  encasement  of  the  gland 
in  an  unyielding  membrane  will  serve,  in  part, 
to  explain  the  severe  pain  felt  in  acute  prostatic 
abscess.  In  acute  prostatitis  pains  are  referred 
over  the  tip  of  the  last  rib  (tenth  dorsal  nerve), 
over  the  posterior  iliac  spine  (eleventh  dorsal 
nerve),  or  even  to  the  soles  of  the  feet  (third- 
sacral  nerve).  It  derives  its  nerve  supply  from 
the  lower  three  dorsal  and  upper  three  sacral 
segments ;  hence  the  widely  distributed  character 
of   the   referred   pains    (Head). 

Hypertrophy  of  the  prostate. — The  average 
measurements  of  the  normal  prostate  are  1^  inch 
across  at  its  widest  part,  and  1\  inch  from  be- 
fore backwards,  or  from  apex  to  base.     After  the 


Chap.  XVIII]       PELVIS    AND    PERINEUM  453 

age  of  fifty-three  the  organ  is  very  apt  to  become 
hypertrophied ;  and,  according  to  Sir  Henry 
Thompson,  this  hypertrophy  may  be^  considered 
to  exist  when  the  gland  measures  2  •  inches  from 
side  to  side,  or  when  it  weighs  1  ounce  or  more. 
The  usual  weight  of  the  prostate  is  6  drachms.  If 
the  enlargement  mainly  affect  the  lateral  parts,  it 
will  be  understood  that  the  hypertrophy  may  at- 
tain considerable  dimensions  without  retention 
of  urine  being  produced.  On  the  other  hand,  a 
comparatively  trifling  enlargement  of  the  median 
commissure  may  almost  entirely  block  the  orifice 
of  the  urethra.  As  this  part  enlarges  it  pushes 
its  way  into  the  bladder  through  the  urethral 
orifice,  dilating  and  destroying  the  sphincter 
vesicae  and  forming  a  mechanical  obstruction  to 
the  free  passage  of  urine  (Fig.  73,  B).  If  the 
affection  be  general,  the  prostatic  urethra  is 
lengthened,  and  if  one  lateral  lobe  be  more  en- 
larged than  the  other,  the  canal  deviates  to  one 
side.  When  the  enlargement  particularly  affects 
the  median  commissure,  the  prostatic  urethra, 
which  is  normally  almost  straight,  becomes  con- 
siderably curved,  the  curve  being  sometimes  very 
abrupt.  It  is  important  to  note  that  enlarge- 
ment of  the  median  commissure  alone  can  hardly 
be  made  out  by  rectal  examination.  The  project- 
ing middle  commissure,  when  viewed  from  the  in- 
terior of  the  bladder,  may  appear  as  a  distinct, 
well-rounded  pedunculated  or  sessile  growth. 

In  the  operation  of  prostatectomy  this  project- 
ing and  most  troublesome  mass  is  removed 
through  a  suprapubic  incision.  Everything 
within  the  sheath  of  the  prostrate — gland,  urethra, 
common  ejaculatory  ducts — is  enucleated  by  the 
surgeon's  finger  through  the  base  of  the  bladder; 
the  sheath  then  encloses  a  space  which  at  first  is 
filled  witn  blood  and  urine,  but  afterwards  con- 
tracts to  form  a  new  urethra.  The  prostrate  is  a 
sexual  organ,  and  its  size  and  development  de- 
pend on  the  presence  and  activity  of  the  testes. 
Castration    prevents    its    development    or    causes 


454  SUKGICAL   APPLIED    ANATOMY    [Part  IV 

atrophy  if  already  developed.  Removal  of  one 
testicle  causes  a  partial  atrophy,  but  section  of 
the  vasa  deferentia  has  usually  no  effect  (C. 
Wallace).  Embedded  in  the  sheath  of  the  pros- 
tate, especially  over  the  groove  between  the  base 
of  the  prostate  and  neck  of  the  bladder,  is  an  ex- 
tensive plexus  of  veins,  the  prostatic  plexus,  into 
which  enters  the  dorsal  vein  of  the  penis  (Fig. 
73  A).  This  plexus  is  cut  in  lateral  lithotomy, 
and  it  is  through  its  vessels  that  septic  matter  is 
probably  absorbed  in  cases  of  pyaemia  following 
that'  operation.  Its  lymphatics,  which  are 
numerous,  pass  to  a  group  of  glands  on  the  wall 
of  the  pelvis,  between  the  external  and  internal 
iliac  arteries. 

The  male  urethra  is  about  8|  inches  in 
length  (21  cm.),  \\  inches  being  devoted  to  the 
prostatic  urethra,  f  of  an  inch  to  the  mem- 
branous, and  6^  inches  to  the  penile  or  spongy 
portion.  Between  the  ages  of  four  and  six  years 
its  length  is  8  to  9  cm.,  and  between  ten  and  thir- 
teen years  10  to  11  cm.  The  canal  may  be  divided 
into  a  fixed  and  movable  part.  The  fixed  part 
extends  from  the  neck  of  the  bladder  to  the 
posterior  extremity  of  the  penile  urethra  at  the 
point  of  attachment  of  the  suspensory  ligament. 
The  fixed  part  describes  an  even  curve,  fairly 
represented  by  the  line  of  a  "  short  curve  "  metal 
catheter.  The  two  ends  of  the  curve  lie  about  in 
the  same  line,  viz.  one  drawn  across  the  lower 
end  of  the  symphysis,  and  at  right  angles  to  the 
vertical  axis  of  that  articulation.  The  curve  is 
formed  around  this  line,  its  centre  summit  corre- 
sponding to  a  prolongation  of  the  vertical  axis  of 
the  symphysis,  and  to  about  the  centre  of  the  mem- 
branous urethra.  This  part  of  the  tube  lies  about 
1  inch  below  the  pubic  arch.  The  movable  portion 
of  the  urethra  forms,  when  the  penis  is  dependent, 
a  second  curve  in  the  opposite  direction,  so  that 
the  whole  canal  follows  somewhat  the  outline  of 
the  letter  S. 
The  prostatic    portion    of  the  urethra  is  nearly 


Chap.  XVIII]       PELVIS    AND    PERINEUM  455 

vertical.  It"  is  surrounded  by  circular  muscular 
fibres  which  may  give  rise  to  a  spasmodic  stricture 
(Fig.  73)-  The  sinus  pocularis  or  uterus  mascu- 
linus,  in  the  floor  of  this  part  of  the  urethra, 
represents  the  united  ends  of  the  rudimentary 
Miillerian  ducts. 

The  penile  or  spongy  portion  of  the  urethra 
is  surrounded  by  the  erectile  tissue  of  the  corpus 
spongiosum  urethrse,  which  is  thickest  on  the 
under  side  of  the  canal.  A  very  thin  layer  of 
erectile  tissue  surrounds  the  membranous  urethra 
lying  beneath  the  fibres  of  the  compressor 
urethrse. 

In  introducing  a  catheter  it  must  be  noted 
that  while  the  instrument  passes  along  the  mov- 
able urethra,  the  canal  accommodates  itself  to  the 
catheter,  but  while  traversing  the  fixed  segment 
the  instrument  must  accommodate  itself  to  the 
unyielding  canal.  In  introducing  a  catheter  in 
the  recumbent  posture  the  penis  is  held  vertically 
upwards,  and  in  this  way  the  curve  formed  by 
the  movable  urethra  is  obliterated.  The  instru- 
ment is  best  kept  close  to  the  surface  of  the  groin, 
and  over  and  parallel  to  Poupart's  ligament. 
When  the  fixed  urethra  is  reached,  the  handle  of 
the  catheter  is  brought  to  the  middle  line,  and 
then,  being  kept  strictly  in  the  median  plane  of 
the  body,  is  depressed  between  the  legs,  so  that  the 
front  of  the  instrument  may  follow  the  natural 
curve  of  the  canal.  The  greatest  difficulty  in  the 
introduction  is  generally  experienced  at  the  point 
where  the  movable  and  fixed  parts  of  the  urethra 
meet;  or,  rather,  in  practice,  at  a  spot  a  little 
behind  this  point,  viz.  at  the  anterior  layer  of 
the  triangular  ligament  (Fig.  73).  At  this  spot 
the  tube  abruptly  becomes  not  only  very  fixed, 
but  also  very  narrow,  and  a  part  of  it  is  reached 
where  muscular  tissue  is  very  abundant,  and 
where  _  resistance  from  muscular  spasm  is  there- 
fore likely  to  be  most  marked. 

It  thus  happens  that  when  a  false  passage  has 
been    made    by    a    catheter    in    a    case    where    no 


456  SUEGICAL    APPLIED    ANATOMY    [Part  IV 

stricture  exists  to  offer  a  definite  obstruction,  the 
instrument  is  usually  found  to  have  left  the  canal 
just  in  front  of  the  triangular  ligament. 

Some  other  points  in  connection  with  cathe- 
terisation  will  be  noted  subsequently. 

The  urethral  canal  must  not  be  regarded 
as  forming  an  open  tube  like  a  gas-pipe.  Except 
when  urine  or  an  instrument  is  passing  along  it, 
the  tube  appears  on  section  as  a  transverse  slit, 
the  superior  and  inferior  walls  being  in  contact. 
This  fact  should  be  remembered  in  amputation  of 
the  penis  by  the  ecraseur.  In  the  fossa  navicu- 
lars the  tube  appears  as  a  vertical  slit. 

The  prostatic  part  of  the  canal  is  the  widest 
and  most  dilutable  portion  of  the  whole  urethra. 
It  is  widest  at  its  centre,  having  here  a  diameter 
of  nearly  \  an  inch ;  at  the  bladder  end  its  dia- 
meter is  about  \  of  an  inch,  while  at  the  anterior 
extremity  of  this  part  of  the  urethra  the  measure- 
ment is  a  little  less  than  \  of  an  inch.  When 
small  catheters  are  being  introduced  their  points 
may  lodge  in  the  orifice  of  the  utricle,  unless  the 
tip  of  the  instrument  be  kept  well  along  the  roof 
of  the  canal.  The  ejaculatory  ducts  open  into  the 
prostatic  urethra,  and  thus  it  happens  that  in- 
flammation of  this  part  of  the  canal  may  spread 
back  along  those  ducts  to  the  seminal  vesicles,  and 
from  thence  along  the  vas  deferens  to  the  epididy- 
mis (Fig.  73).  It  is  by  spreading  along  these 
parts  that  inflammation  of  the  testicle  is  set  up  in 
gonorrhoea  involving  the  prostatic  urethra,  and 
it  will  be  understood  that  a  like  inflammation 
may  follow  lateral  lithotomy,  impacted  stone  in 
the  prostatic  urethra,  prostatic  abscess,  and  the 
like.     Stricture  never  occurs  in  this  part. 

The  membra?wus  urethra  is,  with  the  exception 
of  the  meatus,  the  narrowest  part  of  the  entire 
tube.  Its  diameter  is  about  |  of  an  inch.  It  is 
fixed  between  the  two  layers  of  the  triangular 
ligament,  and  is  the  most  muscular  part  of  the 
canal.  It  is  at  this  spot,  therefore,  that  what  is 
known  as  "  spasmodic  stricture  "  usually  occurs. 


Chap.  XVIII]       PELVIS    AND    PERINEUM  457 

In  any  case,  the  contraction  of  the  constrictor 
urethra?  often  offers  an  appreciable  amount  of  re- 
sistance to  the  passage  of  a  catheter  or  sound 
(Fig.  73). 

The  penile  urethra  is  clilaed  at  either  end, 
viz.  at  the  parts  occupying  the  bulb  and  the  glans 
penis  respectively.  The  diameter  of  the  bulbous 
urethra  is  midway  between  that  of  the  prostatic 
and  membranous  segments  of  the  canal,  while  that 
of  the  greater  part  of  the  penile  urethra  is  mid- 
way between  that  of  the  bulbous  and  membran- 
ous portions.  It  is  in  the  bulbous  urethra  that 
organic  stricture  is  the  most  commonly  met  with. 
The  meatus  measures  from  \  to  \  of  an  inch, 
and  therefore  if  a  catheter  will  pass  the  meatus 
it  will  pass  along  an3^  part  of  the  normal  canal. 
Its  aperture  is  very  resisting,  and  has  often  to 
be  incised  to  allow  the  larger  instruments  to 
pass. 

The  narrowest  parts  of  the  urethra,  therefore, 
are  (1)  at  the  meatus,  and  (2)  in  the  membranous 
segment,  especially  at  its  anterior  end.  It  is 
at  these  points  that  calculi  passed  from  the  blad- 
der are  most  apt  to  lodge.  The  widest  portions 
of  the  canal,  on  the  other  hand,  are  at  (1)  the 
fossa  navicularis,  (2)  the  bulbous  part  of  the 
urethra,  and  (3)  the  centre  of  the  prostatic 
portion. 

Keegan  has  shown  that  the  urethra  of  a  male 
child  two  or  three  years  of  age  will  take  a  No.  9 
catheter.  In  boys  between  eight  and  ten  years  a 
No.  11  lithotrite  may  be  passed. 

It  will  be  obvious,  therefore,  that  the  operation 
of  lithotrity  may  be  performed  upon  quite  young 
male  children,  and  that  fragments  of  crushed 
calculus  of  no  small  dimensions  may  be  removed 
from  the  bladders  of  such  patients  by  washing. 

The  mucous  membrane  presents,  in  addition 
to  many  mucous  glands,  several  lacunae,  the  ori- 
fices of  which  for  the  most  part  open  towards 
the  meatus.  These  lacunae  are  most  numerous  in 
the  bulbous  urethra,  and  occupy  the  floor  rather 


458  SUKGICAL    APPLIED    ANATOMY    [Part  IV 

than  the  roof  of  the  canal.  In  passing  small 
catheters,  therefore,  the  point  of  the  instrument 
should  be  kept  along  the  upper  surface  of  the 
tube,  so  that  it  may  not  become  engaged  in  any 
of  these  spaces.  The  largest  lacuna,  the  lacuna 
magna,  is  situate  in  the  roof  of  the  fossa  navicu- 
lars, and  may  readily  engage  the  point  of  a 
small    instrument. 

The  urethra  may  be  ruptured  by  the  patient 
falling  astride  of  some  hard  substance.  In  such  an 
injury  it  is  crushed  between  the  hard  substance 
and  the  pubic  arch.  The  part  of  the  canal,  there- 
fore, that  is  most  often  damaged  is  the  mem- 
branous segment,  and  the  posterior  part  of  the 
penile  division.  The  more  the  body  is  bent  for- 
wards at  the  time  the  perineum  is  struck,  the 
greater  is  the  length  of  penile  urethra  that  may  be 
crushed  against  the  pubes. 

The  female  urethra  is  about  \\  inch  in 
length,  and  has  a  diameter  of  from  \  to  \  of  an 
inch.  It  is  capable,  however,  of  great  distension. 
In  the  erect  position  the  canal  is  nearly  vertical, 
and  in  the  recumbent  posture  almost  horizontal. 

Pewis. — The  skin  covering  the  bulk  of  the 
organ  is  thin  and  fine,  and  the  subcutaneous  tissue 
is  scanty  and  lax.  It  follows,  from  the  looseness 
of  this  tissue,  that  the  skin  is  very  distensible 
and  movable.  The  latter  fact  should  be  borne 
in  mind  in  circumcision,  for  in  performing  that 
operation  the  skin  of  the  penis  can  be  so  readily 
drawn  forwards  over  and  beyond  the  glans,  that 
if  it  is  excised  as  far  back  as  possible  the  greater 
part  of  the  organ  may  be  left  bare.  This  applies, 
of  course,  mainly  to  children.  The  laxity  of 
the  submucous  tissue  permits  the  organ  to  be- 
come enormously  swollen  when  cedematous,  or 
when  extravasated  urine  finds  its  way  into  the 
part.  Over  the  glans  penis  the  mucous  mem- 
brane is  so  adherent  that  there  is  practically  no 
subcutaneous  tissue.  It  happens,  therefore,  that 
when  Hunterian  chancres  appear  on  this  part 
they  can  never  be  associated  with  other  than  the 


Chap.  XVIII]      PELVIS    AND    PERINEUM 


459 


most  trifling  induration,  there  being  no  tissue  in 
which  the  thickening  can  develop.  At  the  corona, 
on  the  other  hand,  the  submucous  tissue  is  lax 
and  plentiful,  so  that  the  induration  can  readily 
form,  and  it  is  about  this  spot,  therefore,  that  the 
syphilitic  sore  often  attains  its  most  characteristic 
development.  The  vascularity  of  the  penis,  and 
the  rapid  engorgement  that  ensues  when  the  re- 
turn of  its  venous  blood  is  impeded,  serve  to  ex- 
plain the  ready  and  extensive  swelling  of  the 
organ  that  follows  when  any  constricting  band  is 
placed  about  it.  This  should  be  borne  in  mind  in 
tying  in  a  catheter  by  securing  it  by  tapes  around 


Prepuc 
Corp.Caver/mos 

Q  LA/IS 

Lacuna  AIaqna 

Fossa  AIaviculari 

Permanent  AIea 

Primitive  All 

Fig.  74. — Section  of  a  penis  showing  a  common  form  of  hypospadias. 

The  cross  marks  the  point" where  the  tissue  breaks  down  between  the  cloacal 
urethra  and  meatal  ingrowth. 


the  penis.  The  blood  spaces  in  the  corpus  spongi- 
osum may  be  rendered  indistensible  from  gonor- 
rhoeal  inflammation  wThile  those  of  the  corpora 
cavernosa  remain  free.  The  corpus  spongiosum 
then  acts  like  the  string  of  a  bow  during  the  erec- 
tion of  the  penis.  Through  the  superficial  lym- 
phatics disease  may  spread  from  the  skin  and 
meatal  region  of  the  penis  to  the  inner  of  the  in- 
guinal glands.  Deeper  vessels  pass  with  the  pros- 
tatic veins  to  the  internal  iliac  group  of  glands 
on  the  lateral  wall  of  the  pelvis.  Some  vessels 
pass  directly  to  the  external  iliac  glands  through 
the  crural  ring.  The  penis  is  often  the  seat  of 
arrests  of  development,  presenting  a  variety  of 
appearances.  Among  them  may  be  mentioned 
hypospadias,     where    the    inferior    wall     of    the 


460  SURGICAL   APPLIED    ANATOMY    [Part  IV 

urethra  and  corresponding  part  of  the  corpus 
spongiosum  are  wanting,  and  epispadias,  where 
the  superior  wall  of  the  canal  and  corresponding 
parts  of  the  corpora  cavernosa  are  more  or  less 
entirely  deficient.  In  the  condition  of  hypo- 
spadias two  meati  are  present — one  situated  on 
the  glans  opening  into  a  cul-de-sac  which  repre- 
sents the  fossa  navicularis,  and  another  just 
behind  leading  into  the  urethra  (Fig.  74).  Here 
is  seen  the  double  origin  of  the  male  urethra — the 
part  within  the  glans  is  formed  by  an  ingrowth 
of  epithelium  from  the  surface  of  the  glans,  while 
the  rest  of  th,e  penile  urethra  is  derived  from  the 
cloaca.  At  first  the  cloacal  urethra  opens  by  its 
own  orifice  (primitive  meatus,  Fig.  74),  but  in  the 
course  of  development  the  ingrowth  from  the  glans 
takes  place  to  form  the  permanent  meatus  and 
fossa  navicularis ;  when  this  ingrowth  opens  into 
tne  cloacal  urethra  the  primitive  meatus  becomes 
closed.  The  frenum  preputii  is  formed  over  it. 
The  condition  thus  represented  is  one  of  ar- 
rested development.  On  the  prepuce  of  such  cases 
sebaceous  glands  are  arranged  in  two  pigmented 
oval  groups — preputial  ocelli  (Shillitoe). 

Scrotum.  —The  skin  of  the  scrotum  is  thin 
and  transparent,  so  that  in  bruising  of  the  parts 
the  discoloration  due  to  the  extravasation  of 
blood  beneath  the  surface  is  readily  and  distinctly 
seen.  It  is  also  very  elastic,  and  allows  of  great 
distension,  as  is  seen  in  large  scrotal  hernise 
and  testicular  tumours.  The  integument  of  the 
part  is  indeed  redundant,  and  the  excision 
of  a  portion  of  it  will  hardly  be  missed.  Even 
in  gangrene  of  the  scrotum,  when  both  testicles 
have  been  exposed,  the  parts  have  been  entirely 
restored  without  any  inconvenient  shrinking  or 
contraction.  The  rugce  on  the  surface  of  the  scro- 
tum favour  the  accumulation  of  dirt,  and  the 
irritation  set  up  by  such  accumulation  may  be 
the  exciting  cause  of  the  epitheliomata  that  are 
not  uncommon  in  this  part.  When  the  surface  is 
sweating,  the  rugse  tend  to  favour  a  retention  of 


Chap.  XVIII]        PELVIS    AND    PERINEUM  461 

the  moisture  between  their  folds ;  from  this  and 
other  circumstances  it  happens  that  the  scrotum 
is  liable  to  eczema  and  to  those  syphilitic  skin 
disorders  that  are  often  localised  by  irritation. 
The  rugse  are  a  sign  of  health,  since  they  depend 
upon  the  vigorous  contraction  of  the  muscle  fibres 
in  the  dartos  tissue.  In  the  enfeebled,  or  under 
the  relaxing  effects  of  heat,  the  scrotum  becomes 
smooth  and  pendulous.  In  a  simple  incised 
wound,  as  in  castration,  the  dartos  is  apt  to  turn 
in  the  edges  of  the  skin  and  cause  some  difficulty 
in  applying  the  sutures.  This  difficulty  may  be 
avoided  by  relaxing  that  tissue  for  a  while  by  the 
application  of  a  warm  sponge  to  the  wound. 

The  subcutaneous  tissue  is  lax  and  very  ex- 
tensive, and  permits  of  considerable  extravasa- 
tions of  blood  forming  beneath  the  surface.  It  is 
unadvisable,  therefore,  to  apply  leeches  to  the 
scrotum  itself,  since  they  may  lead  to  an  unde- 
sirable outpouring  of  blood  beneath  the  skin,  and 
to  the  appearance  of  a  considerable  ecchymosis. 
Leeches  in  testicular  affections  had  better  be  ap- 
plied over  the  region  of  the  cord. 

The  scrotum,  from  its  dependent  position,  and 
from  the  looseness  and  extent  of  its  cellular  tissue, 
is  often  the  first  part  of  the  body  to  become 
cedematous  in  dropsy,  and  is  apt  to  show  that 
oedema  in  a  marked  degree.  The  scrotum  also  is 
the  part  most  frequently  the  seat  of  elephantiasis, 
which  is  due  essentially  to  a  distension  of  the  lym- 
phatic vessels  and  spaces  of  the  connective  tissue. 
The  vitality  of  the  scrotum  is  not  considerable, 
and  it  therefore  not  unfrequently  sloughs  in 
parts  when  severely  inflamed.  For'  this  reason 
strapping  should  be  applied  with  some  care  over 
the  enlarged  testis,  for  against  the  hard  mass  of 
the  affected  gland  the  integument  of  the  scrotum 
can  be  subjected  to  considerable  pressure  when  the 
strapping  is  tightly  applied.  _  In  such  a  case  I 
have  seen  the  whole  of  one  side  of  the  scrotum 
slough  from  an  indiscreet  use  of  this  familiar 
method  of  treatment. 


462  SURGICAL   APPLIED    ANATOMY    [Part  IV 

The  laxity  of  the  subcutaneous  scrotal  tissues 
is  an  essential  feature  in  those  operations  for  the 
radical  cure  of  inguinal  hernia  where  the  fundus 
of  the  sac  is  invaginated,  through  an  incision  in 
the  scrotum  into  the  orifice  of  the  inguinal  canal. 
Lastly,  the  great  mobility  of  the  scrotum  affords 
an  admirable  source  of  protection  to  the  testicle ; 
for  when  the  part  is  struck  or  squeezed  the  testis 
can  slip  about  within  the  scrotum,  as  a  smooth 
ball  would  within  a  loose  indiarubber  bag,  and 
so  very  often  eludes  all  injury.  , 

The  testicle  may  be  retained  within  the  ab- 
dominal cavity,  or  may  lodge  for  varying  periods 
of  time,  or  for  life,  in  the  inguinal  canal.  It 
may,  on  the  other  hand,  pass  beyond  the  scrotum 
into  the  perineum,  or  may  miss  the  inguinal  canal 
altogether  and  escape  through  the  femoral  canal 
and  saphenous  opening  on  to  the  thigh.  The 
testis  proper  is  entirely  invested  by  the  visceral 
layer  of  the  tunica  vaginalis,  except  over  a  small 
part  of  its  posterior  border  where  the  vessels 
enter.  The  epididymis  is  entirely  covered  by 
the  serous  membrane  at  its  sides,  is  more  or  less 
so  covered  in  front,  but  is  free  or  uncovered 
along  the  greater  part  of  its  posterior  border. 
It. is  about  the  posterior  border  of  the  epididymis 
that  the  visceral  layer  of  the  tunica  vaginalis 
joins  the  parietal  layer.  The  posterior  border  of 
the  testicle  and  of  the  epididymis — from  globus 
major  to  globus  minor— is  bound  by  a  reflection  of 
serous  membrane — the  mesentery  of  the  testicle. 
Instead  of  binding  the  whole  of  the  posterior 
border,  the  mesentery  may  be  attached  merely  to 
the  lower  pole  of  the  testicle  and  globus  minor ; 
on  such  a  pedunculated  attachment  the  testicle 
is  apt  to  become  strangulated  by  a  twisting  of  its 
narrow  mesentery.  The  more  intimate  and  exten- 
sive connection  of  the  serous  tunic  with  the  testis 
or  gland  proper  serves  in  part  to  explain  the 
greater  frequency  with  which  hydrocele  appears 
in  inflammation  of  this  part  of  the  organ,  as 
compared  with   its  occurrence  when  the  epididy- 


Chap.  XVIII]      PELVIS    AND    PERINEUM  463 

mis  is  alone  inflamed.  It  is  owing  to  the  reflec- 
tions of  the  tunica  vaginalis  that  in  cases  of 
common  hydrocele  the  testicle  remains  firmly  set 
at  the  lower  and  posterior  part  of  the  swelling, 
and  yet  so  extensively  is  the  organ  surrounded 
by  that  membrane  that  the  position  of  the  gland 
in  the  larger  hydroceles  is  often  difficult  to  deter- 
mine. In  some  cases  the  testicle  occupies  the  front 
of  the  scrotum,  the  epididymis  being  placed  an- 
teriorly, and  the  body  of  the  gland  being  located 
behind  it.  The  vas  deferens  descends  also  along 
the  front  of  the  cord.  In  these  cases  the  testicle 
is  just  in  the  position  it  would  occupy  if  it  had 
been  turned  round  upon  its  vertical  axis.  The 
condition  is  known  as  inversion  of  the  testicle, 
and  should  be  sought  for  in  cases  of  hydrocele, 
as  in  several  instances  the  testis  has  ^been  pierced 
by  the  trochar  when  tapping  collections  in  cases 
where  the  inversion  existed. 

The  proper  gland  tissue  is  invested  by  a  very 
dense  membrane,  the  tunica  albuginea.  The  epi- 
didymis, on  the  other  hand,  lacks  any  such  firm 
fibrous  investment.  The  unyielding  character  of 
the  tunica  albuginea  serves  in  great  part  to_  ex- 
plain the  intense  pain  felt  in  acute  affections 
of  the  testis  proper,  a  degree  of  pain  which  is 
not  reached  when  the  less  tightly  girt  epididymis 
is  alone  involved.  It  willbe  understood  also  that 
in  inflammation  of  the  epididymis  the  part  swells 
rapidly  and  extensively,  while  in  a  like  affection 
of  the  body  of  the  gland  the  swelling  is  compara- 
tively slow  to  appear. 

It  should  be  borne  in  mind  that  the  lymphatics 
of  the  scrotum  go  to  the  inguinal  glands,  those  of 
the  testicle  to  the  lumbar.  The  testicle  is  de- 
veloped in  front  of  the  tenth  dorsal  vertebra, 
and  receives  its  nerve  supply  from  the  tenth 
dorsal  segment.  Its  nerves  pass  by  the  small 
splanchnics,  solar  and  aortic  plexuses,  to  the 
spermatic  artery,  on  which  they  reach  the  gland. 
The  epididymis  receives  its  nerve  supply  from 
the  pelvic  plexus,  along  the  vas  deferens. 


464  SUKGICAL    APPLIED    ANATOMY    [Part  IV 

The  spermatic  cord, — The  structures  in  the 
cord  are  (l)  the  vas  deferens,  (2)  the  cremaster 
muscle,  (3)  the  spermatic  and  (4)  cremasteric 
arteries,  (5)  the  artery  to  the  vas  deferens, 
(6)  the  pampiniform  plexus  of  veins,  (7)  the 
genito-crural  nerve,  (8)  sympathetic  nerve  fibres, 
and  (9)  lymphatics.  The  vas  deferens  lies  along 
the  posterior  aspect  of  the  cord  (Fig.  ?5),  and 
can  be  detected  by  the  firm,  cord-like  sensation 
which  it  gives  when  pinched  between  the  thumb 
and  finger.  Mr.  Birkett  (Holmes's  "System") 
gives  three  cases  of  rupture  of  the  vas  deferens 


EE— 


Fig.  75. — Section  of  the  left  spermatic  cord  of  an  adult,  at  the  level  of 
the  external  abdominal  ring,  viewed  from  above.  (From  a  specimen 
prepared  by  Mr.  W.  G.  Spencer.) 

vd,  vas  deferens ;  da,  deferential  artery ;  dv,  deferential  veins ;  sa,  spermatic 
artery  ;  ca,  cremasteric  artery ;  cm,  cremaster  muscle  ;  pp,  pampiniform 
plexus. 

during  severe  and  sudden  exertion.  The  duct  ap- 
pears to  have  in  each  case  given  way  within  the 
abdomen  at  some  point  between  the  internal  ring 
and  the  spot  where  it  approaches  the  ureter.  Re- 
section of  part  of  the  vas  has  been  practised  to 
bring  about  atrophv  of  enlarged  prostate,  but  has 
not  proved  successful.  The  size  of  the  cremaster 
muscle  depends  mainly  upon  the  weighty  it  has  to 
suspend.  In  atrophy  of  the  testicle  it  almost 
entirely  disappears,  while  in  cases  of  large  slow- 
growing  tumours  of  the  gland  it  attains  consider- 
able proportions.  If  in  children  or  young  adults 
the  skin  over  the  middle  of  the  thigh  just  below 
Poupart's  ligament  be  tickled  the  testicle  of  the 


Chap.  XVIIIj      PELVIS    AND    PERINEUM  465 

same  side  will  usually  be  seen  to  be  suddenly 
drawn  upwards.  The  tickling  concerns  the  crural 
branch  of  the  genito-crural,  while  the  motor  nerve 
of  the  cremaster  is  the  genital  division  of  the  same 
trunk.  The  interval  of  time  that  elapses  between 
the  irritation  of  the  skin  and  the  movement  of 
the  testicle  has  been  appealed  to  as  affording  evi- 
dence of  the  state  of  nerve  health  and  of  the 
readiness  with  which  nerve  impulses  are  con- 
ducted. Of  the  arteries,  the  spermatic  comes  from 
the  aorta  and  lies  in  front  of  the  vas,  the  cre- 
masteric arises  from  the  deep  epigastric  and  lies 
among  the  superficial  layers  of  the  cord  in  its 
outer  segment,  while  the  deferential  artery  from 
the  superior  or  inferior  vesical  lies  by  the  side  of 
the  vas  (Fig.  75).  The  first-named  vessel  is  the 
size  of  the  posterior  auricular,  and  the  two  latter 
the  size  of  the  supraorbital.  The  spermatic  artery 
divides  into  a  number  of  branches  as  it  reaches 
the  testicle ;  these  branches  pass  to  the  inner  side 
of  the  epididymis,  which  may  be  removed  without 
interfering  with  the  blood  supply  of  the  testicle. 
The  three  arteries  of  the  cord  are  divided  in 
castration,  and  may  all  require  ligature.  It  is 
advisable  to  secure  the  vessels  in  sections,  rather 
than  adopt  the  clumsy  plan  of  involving  the  whole 
cord  in  one  common  ligature.  The  veins  are 
divided  roughly  into  two  sets.  The  anterior  is 
by  far  the  larger  set,  runs  with  the  spermatic 
artery,  and  forms  the  pampiniform  plexus.  The 
posterior  set  is  small  and  surrounds  the  vas,  run- 
ning with  the  deferential  artery.  The  veins  of 
the  spermatic  and  pampiniform  plexus  are  very 
frequently  varicose,  and  then  constitute  the  affec- 
tion known  as  varicocele.  Many  anatomical 
causes  render  these  veins  liable  to  this  affection  : 
they  occupy  a  dependent  position,  and  the  main 
vein  is  of  considerable  length,  and  follows  a 
nearly  vertical  course ;  the  vessels  are  very  large 
when  compared  with  the  corresponding  artery, 
and  so  the  vis  a  tergo  must  be  reduced  to  a  mini- 
mum :  they  occupy  a  loose  tissue,  and  are  lacking 
2e 


466  SURGICAL   APPLIED    ANATOMY    [Part  IV 

in  support  and  in  the  aid  afforded  to  other  veins 
(as  in  the  limbs)  by  muscular  contraction;  they 
are  very  tortuous,  form  many  anastomoses,  and 
have  few  and  imperfect  valves;  they  are  exposed 
to  pressure  in  their  passage  through  the  inguinal 
canal.  The  left  veins  are  more  frequently  affected 
than  the  right.  Mr.  Spencer  has  shown  that  the 
veins  in  the  left  cord  are  always  much  larger 
than  those  of  the  right.  It  may  also  be  pointed 
out  that  the  left  testicle  hangs  lower  than  the 
right ;  that  the  left  spermatic  vein  enters  the  left 
renal  at  a  right  angle,  while  the  right  spermatic 
vein  passes  Obliquely  into  the  vena  cava ;  and  that 
the  left  vein  passes  beneath  the  sigmoid  flexure, 
and  is  thus  exposed  to  pressure  from  the  contents 
of  that  bowel.  The  congenital  origin  of  vari- 
cocele is  now  very  generally  allowed. 

When  the  varicose  veins  are  exposed  by  opera- 
tion it  is  impossible  to  isolate  or  even  recognise 
the  arteries. 

The  female  generative  organs  require 
but  little  notice  in  the  present  volume.  The 
labia  majora  have  the  same  pathological  tenden- 
cies as  has  the  scrotum,  to  which,  indeed,  they 
anatomically  correspond.  They  are  liable  to 
present  large  extravasations  of  blood,  are  greatly 
swollen  when  cedematous,  are  prone  to  slough 
when  acutely  inflamed,  and  are  the  usual  seats  of 
elephantiasis  in  the  female.  A  hernia  may  pre- 
sent in  one  or  other  labium  (pudendal  hernia), 
the  neck  of  the  sac  being  between  the  vagina  and 
the   pubic  ramus. 

"  On  everting  one  of  the  labia  minora  and 
pressing  the  hymen  inwards,  a  small  red  de- 
pression may  generally  be  seen  on  the  vulva, 
somewhat  posteriorly.  It  leads  to  the  orifice  for 
Bartholin's  gland  ;;  (Doran).  This  gland,  an  oval 
body  about  \  an  inch  in  length,  lies  against  the 
posterior  part  of  the  vaginal  orifice,  under  the 
superficial  perineal  fascia,  and  covered  by  the 
fibres  of  the  sphincter  vaginae.  It  wastes  after 
thirty.     It  corresponds  to  the  gland  of   Cowper 


Chap.  XVIIIJ      PELVIS    AND    PERINEUM  467 

in  the  male  (Fig.  73,  p.  451).  Both  are  apt  to 
become  the  sites  of  chronic  gonorrhoea!  inflamma- 
tion. Abscess  of  the  gland  and  cystic  dilatation 
of  its  duct  are  not  uncommon. 

The  vagina  is  lodged  between  the  bladder  and 
rectum,  while  the  upper  fourth  of  its  posterior 
surface  is  covered  with  peritoneum,  and  is  there- 
fore in  relation  to  the  abdominal  cavity.  Thus  it 
happens  that  the  bladder,  the  rectum,  or  the 
small  intestines  may  protrude  into  the  vagina  by 
a  yielding  of  some  parts  of  its  walls  and  thus  pro- 
duce a  vaginal  cystocele,  rectocele,  or  entero- 
cele. 

The  anterior  wall  of  the  vagina  measures  a 
little  over  2  inches,  the  posterior  wall  about  3 
inches.  The  long  axis  of  the  canal  forms  an  angle 
of  60°  with  the  horizon,  and  is  therefore  almost 
parallel  to  the  pelvic  brim.  The  loose  areolar 
tissue  at  the  base  of  the  broad  ligament  lies  on 
each  side  of  the  upper  extremity  of  the  vagina. 
The  ureter  terminates  in  the  bladder,  on  the  upper 
part  of  the  vaginal  roof. 

The  abdominal  cavity  may  be  opened  through 
a  wound  of  the  vagina.  In  one  or  two  instances 
of  such  injuries  several  feet  of  intestine  have  pro- 
truded through  the  vulva.  In  one  reported  case 
an  old  woman,  the  subject  of  a  brutal  rape, 
walked  nearly  a  mile  with  several  coils  of  the 
small  bowel  hanging   from  her   genitals. 

From  the  comparative  thinness  of  the  walls 
that  separate  the  vagina  from  the  bladder  and 
rectum,  it  happens  that  vesico-vaginal  and  recto- 
vaginal fistulas  are  of  frequent  occurrence.  The 
vagina  is  very  vascular,  and  wounds  of  its  walls 
have  led  to  fatal  haemorrhage.  It  is  very  dilat- 
able, as  can  be  shown  when  the  canal  is  plugged 
to  arrest  haemorrhage  from  the  uterus. 

The  uterus  weighs  about  one  ounce.  The 
uterine  cavity  and  the  cervical  canal  together 
measure  about  2^  inches.  This  must  be  borne  in 
mind  when  passing  a  uterine  sound.  The  blood- 
vessels   run    transversely    to    the    length    of    the 


468  SURGICAL   APPLIED    ANATOMY    [Part  IV 

uterus,  so  that  a  ligature  may  be  placed  com- 
pletely around  the  organ  without  affecting  the 
circulation  above  or  below.  Ligature  of  the  uterine 
artery  has  been  practised  to  arrest  the  growth  of 
uterine  tumours.  The  artery  rises  from  the  in- 
ternal iliac  \  an  inch  below  the  pelvic  brim  and 
passes  to  the  neck  of  the  uterus  in  the  broad  liga- 
ment. It  is  2\  inches  long  and  loops  over  the 
ureter  midway  in  its  course.  It  is  reached  by 
incising  the  broad  ligament  between  the  Fallopian 
tube  behind  and  the  round  ligament  in  front.  It 
is  found  in  the  loose  areolar  tissue  under  the 
wound. 

The  lymphatics  from  the  fundus  of  the  uterus 
and  appendages  pass  to  the  lumbar  glands,  a  few 
also  pass  along  the  round  ligament  to  the  in- 
guinal glands.  The  lymphatics  of  the  cervix, 
which  is  frequently  the  seat  of  cancer,  pass  to 
the  internal  iliac  glands  on  the  lateral  wall  of 
the  pelvis. 

The  unimpregnated  uterus  is  very  rarely 
wounded,  owing  its  immunity  to  the  denseness  of 
its  walls,  to  its  small  size,  to  its  great  mobility, 
and  to  its  position  within  the  bony  pelvis. 

The  ovary  is  so  placed  that  the  outer  part  of 
the  Fallopian  tube  turns  downwards  externally  to 
it.  The  more  common  position  of  the  ovary  may 
be  indicated  on  the  surface  of  the  body  by  the 
line  employed  to  mark  out  the  course  of  the 
common  and  external  iliac  arteries — a  line  drawn 
from  the  aortic  bifurcation  to  the,  femoral  point 
(Fig.  57,  p.  340).  The  ovary  lies  internally  to  the 
mid  point  of  this  line  (Fig.  70,  p.  418).  It  lies 
in  the  angle  between  the  external  and  internal 
iliac  arteries  and  may  be  indistinctly  palpated 
through  the  vagina.  Its  nerves  come  from  the 
tenth  dorsal  segment  of  the  cord.  The  sensory 
nerves  for  the  cervix  are  derived  from  the  lower 
sacral  segments.  The  lymphatics  of  the  ovary 
pass  to  the  lumbar  glands.  The  ovaries  exert  a 
very  marked  trophic  influence  on  the  breast;  the 
hypertrophy   of  the  mammae   at  puberty   and   in 


Chap.  XVIII]        PELVIS    AND    PERINEUM  469 

pregnancy  depends  on  an  internal  secretion  of 
the  ovary  (Starling).  By  their  removal  it  was 
hoped  that  cancer  of  the  breast  might  be  arrested, 
but  the  procedure  has  not  been  followed  by  much 
success.  At  the  brim  of  the  pelvis  the  ovarian 
vessels  lie  within  a  fold  of  peritoneum,  named 
the  ovario-  or  infundibulo-pelvic  ligament,  for  it 
is  attached  both  to  the  ovary  and  to  the  infundi- 
bulum  of  the  Fallopian  tube.  This  ligament 
forms  the  outer  part  of  the  pedicle  in  ovariotomy. 

The  rectum  in  the  adult  is  situated  entirely 
within  the  true  pelvis,  and  presents  three  marked 
curves,  one  in  the  lateral  and  two  in  the  antero- 
posterior direction  (see  p.  390).  In  the  infant, 
however,  a  good  deal  of  the  rectum  is  in  the 
abdominal  rather  than  the  pelvic  cavity,  the  gut 
is  nearly  straight,  and  occupies  a  more  or  less 
vertical  position.  For  these  reasons,  _  together 
with  the  fact  that  the  sacrum  is  straight,  the 
prostate  small,  and  the  connections  of  the  bowel 
loose,  prolapsus  ani  is  much  more  common  in 
children  than  in  adults.  Children  are,  besides, 
especially  liable  to  such  exciting  causes  of  pro- 
lapse as  worms  and  rectal  polypi. 

The  rectum  commences  in  front  of  the  third 
sacral  vertebra  and  is  about  5  inches  in  length. 
It  is  continuous  with  the  pelvic  colon,  which  is 
invested  by  peritoneum  and  supported  by  a 
mesentery.  The  serous  membrane  gradually 
leaves  its  posterior  surface,  then  its  sides,  and 
lastly  its  anterior  surface.  Anteriorly,  the  peri- 
toneum, in  the  form  of  the  recto-vesical  pouch, 
extends  in  the  male  to  within  3  inches  of  the  anus, 
while  on  the  posterior  aspect  of  the  gut  there  is 
no  peritoneum  below  a  spot  5  inches  from  the 
anus.  Thus,  in  excision  of  the  rectum,  more  of 
the  bowel  can  be  removed  on  the  posterior  than 
on  the  anterior  part  of  the  tube  without  opening 
the  peritoneal  cavity.  It  will  be  seen,  also,  that 
carcinomatous  and  other  spreading  ulcers  are 
more  apt  to  invade  the  peritoneal  cavity  when 
they    are    situated    in    the    anterior    wall   of    the 


4?0  StJEGtCAL   APPLIED    ANATOMY    [Part  IV 

intestine.  The  lower  part  of  the  rectum,  distin- 
guished as  the  anal  canal,  is  surrounded  by  the 
internal  sphincter — an  involuntary  muscle  con- 
tinuous with  the  circular  coat.  In  the  condition 
of  rest  the  anal  canal,  which  is  directed  down- 
wards and  backwards,  measures  l\  inch,  but 
during  defsecation  and  when  the  patient  bears 
down,  it  assumes  a  shallow  annular  form.  The 
canal  is  firmly  fixed  to  the  levatores  ani ;  hence 
in  prolapse  it  is  the  rectum  above  the  canal  which 
is  extruded  through  the  anus.  Mr.  Cripps  has 
shown  that  the  posterior  edge  of  the  levator  ani 
forms  a  distinctly  felt  free  border,  which  crosses 
the  rectum,  nearly  at  a  right  angle  at  a  point 
from  1^  to  2  inches  from  the  anus. 

By  inserting  the  finger  into  the  rectum  the 
prostate  and  seminal  vesicles  can  be  readily  felt 
and  examined,  and  that  triangular  surface  of  the 
bladder  explored  through  which  puncture  per 
rectum  is  made  (p.  446). 

It  will  be  understood  that  the  prostate,  when 
enlarged,  may  encroach  upon  the  cavity  of  the 
rectum  and  greatly  narrow  its  lumen  (Fig.  73). 
The  position  of  the  seminal  vesicles  with  regard 
to  the  bowel  is  such  that  in  violent  attempts  at 
defsecation  they  may  be  pressed  upon  by  the  rectal 
contents,  and  so  in  part  emptied,  producing  a 
kind  of  spermatorrhoea.  Defsecation  also  often 
causes  much  pain  in  inflammatory  affections  of 
the  prostate  and  adjacent  parts. 

The  anterior  surface  of  the  rectum  in  the 
female  is  in  relation,  so  far  as  the  finger  can 
reach,  with  the  vagina,  and  in  examining  the 
lower  part  of  the  rectum,  it  is  convenient  to  pro- 
trude its  mucous  membrane  through  the  anus  by 
means  of  the  finger  introduced  into  the  genital 
passage. 

The  rectum  is  dilated,  and  is  very  distensible 
just  above  the  anus.  In  faecal  accumulations  it 
may  be  distended  to  a  considerable  size,  and 
strange  foreign  bodies  of  large  dimensions  have 
been    found    in    the    ampulla.     Among   the   latter 


Chap.  XVIII]      PELVIS    AND    PERINEUM  471 

may  be  mentioned  a  bullock's  horn,  an  iron 
match  -  box,  and  a  glass  tumbler.  By  anti- 
peristaltic movements  of  the  colon,  such  bodies 
may  be  carried  towards  the  caecum.  Thus  a  case 
is  recently  reported  by  Alexander  in  which  the 
handle  of  an  umbrella,  accidentally  lodged  in  the 
rectum,  was  removed  by  the  surgeon  two  weeks 
later  from  the  hepatic  flexure  of  the  colon.  Ex- 
periment has  shown  that  when  the  rectum  is  dis- 
tended in  the  male,  the  recto-vesical  fold  of  peri- 
toneum is  raised,  and  the  bladder  is  elevated  and 
pushed  forwards.  In  the  female  the  fundus  uteri 
is  raised  and  pushed  towards  the  symphysis. 
The  rectum  is  artificially  distended  in  suprapubic 
lithotomy,  in  order  to  bring  the  bladder  into 
better  position  (p.  443).  Normally  the  rectum  is 
empty  except  during  defalcation.  Advantage  of 
this  circumstance  is  taken  in  operations  for  the 
cure  of  ectopia  vesicae  where  the  ureters  are  re- 
moved from  the  exposed  bladder  and  implanted  in 
the  rectum. 

If  the  sphincter  be  very  gradually  dilated,  the 
entire  hand,  if  small,  may  be  introduced  into  the 
rectum  in  both  males  and  females.  The  circum- 
ference of  the  hand  should  not  exceed  8  inches. 
By  a  semi-rotary  movement,  and  by  alternately 
flexing  and  extending  the  fingers,  the  hand  can  be 
insinuated  into  the  commencement  of  the  sigmoid 
flexure.  Owing  to  the  mobility  of  this  part  of 
the  bowel  a  large  extent  of  the  abdomen  may  be 
explored  through  the  bowel  wall.  The  structures 
that  can  be  readily  felt  are  the  kidneys,  the  aorta, 
the  iliac  vessels,  the  uterus  and  ovaries,  the 
bladder  and  its  surroundings,  the  pelvic  brim, 
the  sacro-sciatic  foramina,  the  ischial  spine,  the 
sacrum,  etc.  In  some  subjects  even  a  small  hand 
cannot  be  passed  beyond  the  reflection  of  the  peri- 
toneum over  the  second  part  of  the  gut.  In  such 
instances  the  peritoneum  offers  a  resistance  like  a 
tight  garter,  and  prevents  the  farther  advance  of 
the  hand  without  great  risk  of  laceration  of  the 
parts  (Walsham). 


472  SUEGICAL   APPLIED    ANATOMY    [Part  IV 

Owing  to  the  constrained  position  of  the  hand 
and  the  cramping  of  the  fingers,  this  method  of 
examination  has  proved  to  be  of  but  limited  ser- 
vice. 

The  attachments  of  the  rectum  by  means  of  the 
pelvic  fascia  are  not  very  firm;  since,  in  some 
severe  and  rare  cases  of  prolapse,  all  the  walls 
of  the  gut  may  be  protruded  at  the  anus  {see 
p.  431).  In  excision  of  the  rectum,  also,  advantage 
is  taken  of  this  mobility. 

The  mucous  membrane  is  thick,   vascular,   and 
but    loosely    attached    to    the    muscular    coat    be- 
neath.    This    laxity,    which    is    more    marked    in 
children,  favours  prolapse,  an  affection  in  which 
the  mucous  membrane  of  the  lower   part  of  the 
rectum  'is   protruded   at   the   anus.     The   mucous 
membrane    presents    three    prominent    semilunar 
folds,  about  \  an  inch  in  depth,  which  are  placed 
more  or  less  transversely  to  the  long  axis  of  the 
bowel.     The  first  projects  backwards  from  the  fore 
-part    of    the    rectum    opposite    the    prostate,    the 
second  projects  inwards  from  the  left  side  of  the 
tube  opposite  the  middle  of  the  sacrum,  the  third 
is   near   the   commencement  of   the   bowel   on   the 
right   side.     These    rectal   folds,    especially    when 
the  gut  is  empty,   may  offer  considerable  resist- 
ance   to    the    introduction    of    a    bougie    or    long 
enema  tube,   and  their  position  should  be  there- 
fore borne  in  mind. 

The  vessels,  and  especially  the  veins,  at  the 
lower  part  of  the  rectum,  are  apt  to  become  vari- 
cose and  dilated,  and  form  piles.  The  tendency 
to  piles  can  in  part  be  explained  by  the  dependent 
position  of  the  rectum,  by  the  pressure  effects  of 
hardened  faeces  upon  the  returning  veins,  and  by 
the  fact  that  part  of  the  venous  blood  returns 
through  the  systemic  system  (internal  iliac  vein) 
and  part  through  the  portal  system  (inferior 
mesenteric  vein).  This  connection  with  the  portal 
trunk  causes  the  rectum  to  participate  in  the 
many  forms  of  congestion  incident  to  that  vein. 
The  veins  of  the  rectum,  also,  can  be  affected  by 


Char.  XVIII]      PELYIS    AND    PERINEUM  473 

violent  expiratory  efforts.  For  the  last  4  inches 
of  the  bowel,  moreover,  the  arrangement  of  the 
vessels  is  peculiar,  and  is  such  as  to  favour  vari- 
cosity. The  arteries,  "  having  penetrated  the 
muscular  coats  at  different  heights,  assume  a 
longitudinal  direction,  passing  in  parallel  lines 
towards  the  edge  of  the  bowel.  In  their  progress 
downwards  they  communicate  with  one  another  at 
intervals,  and  they  are  very  freely  connected  near 
the  orifice,  where  all  the  arteries  join,  by  trans- 
verse branches  of  considerable  size  ;;  (Quain). 
The  veins  form  a  plexus  with  a  precisely  similar 
arrangement.  The  veins  beneath  the  mucous  mem- 
brane of  the  anal  canal  perforate  the  muscular 
coat  of  the  rectum  about  1  inch  above  the  anal 
canal.  At  the  point  of  perforation  they  are  liable 
to  be  compressed. 

The  lymphatics  of  the  rectum  pass  to  the  in- 
ternal iiiac  group  of  lymphatic  glands  on  the 
lateral  wall  of  the  pelvis.  Hence  in  cancer  of  the 
lower  part  of  the  rectum  these  glands  and  the 
vessels  leading  to  them  are  the  earliest  seats  of 
secondary  infections.  The  lymphatics  of  the  pel- 
vic colon  pass  to  the  glands  in  front  of  the  sacrum 
and  to  others  between  the  layers  of  the  meso- 
rectum. 

The  rectum  may  be  most  freely  exposed  from 
behind  (Fig;.  71,  p.  434).  In  Kraske's  operation 
for  the  extirpation  of  cancer  of  the  rectum  an 
incision  is  made  along  the  sacrum  in  the  middle 
line,  from  the  level  of  the  posterior  inferior  iliac 
spine  to  the  anus.  A  flap  is  turned  out  on  the  left 
side,  including  the  skin  and  origin  of  the  gluteus 
maximus.  The  attachments  of  the  left  sacro-sciatic 
ligaments,  coccygeus,  and  levator  ani,  to  the  sacrum 
and  coccyx  are  divided  and  turned  outwards. 
The  lateral  and  median  sacral  arteries  and  a 
plexus  of  veins  are  raised  with  the  fibrous  tissue 
from  the  anterior  surface  of  the  sacrum  by  a  peri- 
osteal elevator.  The  left  halves  of  the  fourth  and 
fifth  sacral  vertebrae,  with  the  left  half  of  the 
coccyx,  are  removed.     The  fourth,  fifth  sacral  and 


4?4  SURGICAL   APPLIED    ANATOMY    [Part  IV 

coccygeal  nerves  are  necessarily  cut,  but  an  at- 
tempt should  be  made  to  save  the  third  sacral 
nerve,  owing  to  the  importance  of  its  function. 
The  rectum  is  then  exposed,  with  the  hsemor' 
rhoidal  vessels  and  reflection  of  peritoneum.  By 
opening  the  peritoneal  cavity  part  of  the  pelvic 
colon  may  be  brought  into  the  wound.  After  the 
diseased  part  is  removed,  with  the  presacral  and 
internal  iliac  lymphatic  glands,  the  upper  end  of 
the  rectum  is  brought  down  and  sutured  to  the 
anal  part.  An  attempt  should  be  made  to  save 
the  levator  ani  and  third  sacral  nerve,  in  order 
that  the  integrity  of  the  pelvic  diaphragm  may 
be  maintained.  The  rectum  is  supplied  with 
sensory  and  motor  nerves  from  the  second,  third, 
and  fourth  sacral  segments  through  the  corre- 
sponding nerves.  Some  motor  nerves  are  also 
derived  from  the  lower  two  dorsal  and  upper 
lumbar  segments.  These  nerves  reach  the  rectum 
through  the  hypogastric  and  pelvic  plexuses. 

Anus.  —  The  skin  about  the  anus  is  thrown 
into  numerous  folds,  and  it  is  in  these  that  the 
ulcer  or  fissure  of  the  anus  forms.  When  the  anal 
canal  is  closed  the  vertical  columns  of  Morgagni 
meet.  At  their  upper  and  at  their  lower  ends 
they  are  united  by  small  valvular  folds  of  mem- 
brane, which  prevent  the  escape  of  liquid  contents. 
The  lower  valves  may  be  torn  by  the  passing 
scybalous  masses,  and  from  the  rent  thus  caused 
a  fissure  of  the  anus  may  be  produced  (Ball).  The 
extreme  painfulness  of  these  ulcers  is  due  to  the 
exposure  of  a  nerve-fibre  at  their  base,  and  to  the 
constant  contraction  of  the  sphincter  muscle  that 
they  excite.  Relief  is  given  by  excising  the  base 
of  the  ulcer,  so  as  to  divide  some  part  of  the 
sphincter  ;  or  by  violently  dilating  the  anus,  so  as 
to  tear  up  the  base  of  the  ulcer  and  paralyse  for 
a  while  the  action  of  the  disturbing  muscle.  Below 
the  columns  of  Morgagni  a  fine  white  line  surrounds 
the  anus  at  the  junction  of  the  skin  and  mucous 
membrane,  and  indicates  the  interval  between  the 
external  and  internal  sphincters  (Hilton). 


Chap.  XVIII]       PELVIS    AND    PERINEUM  4?5 

The  anus  may  be  torn  during  defsecation,  when 
the  stools  are  hard.  A  case  is  reported  of  a 
woman  who,  during  violent  efforts  at  defsecation, 
felt  something  give  way,  and  discovered  faeces  in 
her  vagina.  The  recto-vaginal  wall  had  ruptured 
2  inches  from  the  anus.  During  labour  the  child's 
head  has  passed  into  the  rectum,  and  has  been 
delivered  per  anum. 

An  imperforate  anus  is  the  most  common 
congenital  defect  of  the  rectum.  This  condition 
represents  an  arrest  of  development.  The  forma- 
tion of  the  anus  is  a  double  process;  first  there  is 
an  ingrowth  from  the  perineum,  and  secondly  a 
downgrowth  from  the  bowel,  these  two  elements 
meeting  and  communicating  near  the  upper  end 
of  the  anal  canal.  In  many  cases  of  imperforate 
anus,  only  a  thin  anal  membrane  requires  to  be 
broken  down  to  allow  the  free  passage  of  faeces, 
but  in  other  cases  the  defect  is  much  greater,  the 
anal  canal,  and  even  the  rectum,  being  completely 
wanting.  NTot  unfrequently  in  such  cases  the  rec- 
tum may  communicate  with  the  urethra  in  the 
male  or  with  the  vulval  cleft  in  the  female.  This 
communication  is  due  to  the  persistence  of  an 
embryonic  condition. 

Nerves  of  pelvis  and  perineum.  —  The 
pelvic  viscera  are  supplied  by  the  pelvic  plexus  of 
the  sympathetic.  This  plexus  is  joined  by  at  least 
three  spinal  nerves,  the  second,  third,  and  fourth 
sacral. 

It  is  well  known  that  in  certain  affections  of 
the  bladder,  rectum,  prostate,  etc.,  pain  is  felt 
along  the  perineum,  in  the  penis,  over  the  but- 
tock, and  down  the  thigh.  These  parts  are  sup- 
plied by  the  pudic  and  small  sciatic  nerves,  and 
the  reason  for  the  pain  is  explained  by  the  origin 
of  the  sensory  nerves  for  those  organs  from  the 
same  and  adjoining  segments  of  the  spinal  cord. 
The  upper  part  of  the  rectum  is  provided  with 
but_  little  sensation,  as  illustrated  by  the  passage 
of  instruments,  by  the  comparative  painlessness 
of  malignant  and  other  growths  high  up  in  the 


476  SURGICAL   APPLIED    ANATOMY    [Part  IV 

bowel,  and  by  the  little  inconvenience  felt  when 
the  gut  is  distended  with  hardened  faeces.  From 
this  apathy  it  has  probably  happened  that,  in  the 
self-administration  of  enemata,  patients  have 
thrust  the  tube  through  the  rectum  into  the  peri- 
toneal cavity.  The  anal  canal,  on  the  other  hand, 
is  extremely  sensitive. 

The  nerve  relations  between  the  anus  and  the 
neck  of  the  bladder  are  very  intimate.  Painful 
affections  of  the  anus  often  cause  bladder  troubles, 
and  retention  of  urine  is  very  common  after 
operations  upon  piles.  Maladies,  on  the  other 
hand,  that  involve  the  bladder  neck  are  often 
associated  with  tenesmus  and  anal  discomfort. 
This  relation  is  maintained  by  the  pelvic  plexus, 
but  mainly  by  the  fourth  sacral  nerve.  This 
nerve  gives  special  branches  direct  to  the  neck  of 
the  bladder,  and  then  goes  to  supply  the  muscles 
of  the  anus  (the  sphincter  and  levator)  and  the 
integument  between  the  anus  and  the  coccyx. 

The  mucous  membrane  of  the  urethra,  the  mus- 
cles of  the  penis,  and  the  greater  part  of  the  skin 
of  the  penis,  scrotum,  perineum,  and  anus,  are 
supplied,  from  the  second,  third,  and  fourth 
sacral  segments,  by  the  pudic  nerve.  Thus,  it 
will  be  understood  that  irritation  applied  to  the 
urethra  may  cause  erection  of  the  penis  (as  illus- 
trated by  chordee  in  gonorrhoea),  or  may  produce 
contraction  of  the  urethral  muscles  (as  seen  in 
some  forms  of  spasmodic  stricture).  The  disturb- 
ance caused  by  accumulated  secretion  beneath  the 
prepuce  in  young  children  may  provoke  great 
irritability  of  the  organ,  and  it  is  well  known 
that  painful  affections  of  the  perineum  and  anus 
may  be  associated  with  priapism.  The  distribu- 
tion of  the  third  sacral  segment  in  the  perineum 
by  means  of  the  long  pudendal  nerve  will  explain 
the  pain  about  the  buttock  and  down  the  back  of 
the  thigh  that  is  often  complained  of  during  the 
growth  of  perineal  abscess  and  in  painful  affec- 
tions of  the  scrotum.  This  nerve  crosses  just  in 
front  of  the  tuber  ischii,   and  may  be  so  pressed 


Chap.  XVIII]      PELVIS    AND    PERINEUM  477 

upon  by  using  a  hard  seat  as  to  cause  one-sided 
neuralgia  of  the  penis  and  scrotum.  It  is  also 
in  close  connection  with  the  ischial  bursa,  and 
neuralgia  of  the  same  parts  has  been  met  with  in 
cases  of  inflammation  involving  that  structure. 

The  testicle  is  supplied  mainly  from  the  tenth 
dorsal  segment  by  the  spermatic  plexus.  The  kid- 
ney is  also  partly  supplied  from  the  same  segment. 
This  is  illustrated  by  the  pain  felt  in  the  renal 
region  during  neuralgia  of  the  testicle,  and  by  the 
pain  felt  in  the  testicle,  the  vigorous  retraction 
of  that  organ  observed  in  certain  affections  of  the 
kidney,  such  as  in  acute  nephritis,  and  in  the 
passage  of  renal  calculi.  By  means  of  the  renal 
plexus  the  testicle  is  brought  into  direct  com- 
munication with  the  semilunar  ganglia  and  solar 
plexus,  which  receives  some  of  the  terminal  fibres 
of  the  vagus.  This  communication  serves  to  ex- 
plain_  the  great  collapse  often  noticed  in  sudden 
injuries  to  the  testicle,  and  especially  the  marked 
tendency  to  vomit,  _  so  often  observed  in  such 
lesions.  _  So  far  as  its  nerves  are  concerned,  the 
testicle  is  nearly  in  as  intimate  relation  with  the 
great  nerve-centre  of  the  abdomen  as  is  a  great 
part  of  the  small  intestine,  and  one  would  expect 
a  sudden  crush  of  the  testis  to  be  associated  with 
as  severe  general  symptoms  as  would  accompany 
a  sudden  nipping  of  the  ileum  in  a  rupture. 
Such  a  resemblance  in  symptoms  is  actually  to  be 
observed  in  practice. 


PART  V.-THE  LOWER  EXTREMITY 

CHAPTER   XIX, 

,    THE    REGION    OF    THE    HIP 

This  region  will  be  considered  under  the  follow- 
ing heads  :  1.  The  buttocks.  2.  The  region  of 
Scarpa's  triangle.  3.  The  hip-joint.  4.  The  upper 
third  of  the  femur. 

1,  The  buttocks.  — Surface  anatomy.  —  The 
bony  points  about  the  gluteal  region  can  be  well 
made  out.  The  crest  of  the  ilium  is  distinct,  as 
is  also  the  anterior  superior  spine.  The  posterior 
superior  spine  is  less  evident,  but  can  be  readily 
felt  by  following  the  crest  to  its  posterior  termina- 
tion. This  spine  is  on  a  level  with  the  second  sacral 
spine,  and  is  placed  just  behind  the  centre  of  the 
sacro-iliac  articulation.  The  great  trochanter  is 
a  conspicuous  landmark.  It  is  covered  by  the 
fascial  insertion  of  the  gluteus  maximus.  Its 
upper  border  is  on  a  level  with  the  centre  of  the 
hip-joint,  and  is  somewhat  obscured  by  the  tendon 
of  the  gluteus  medius  which  passes  over  it.  The 
comparatively  slight  prominence  of  the  trochanter 
in  the  living  subject,  as  compared  with  the  great 
projection  it  forms  in  the  skeleton,  depends  upon 
the  completeness  with  which  the  gluteus  medius 
and  minimus  fill  up  the  hollow  between  the  tro- 
chanter and  the  ilium.  When  these  muscles  are 
atrophied  the  process  becomes  very  conspicuous. 
In  fat  individuals  its  position  is  indicated  by  a 
slight  but  distinct  depression  over  the  hip. 

If  a  line  be  drawn  from  the  anterior  superior 

478 


Chap.  XIX1  REGION    OF   THE   HIP  479 

spine  to  the  most  prominent  part  of  the  tuber 
ischii,  it  will  cross  the  centre  of  the  acetabulum, 
and  will  hit  the  top  of  the  trochanter.  This  line, 
known  as  Nelaton's  line,  is  frequently  made  use 
of  in  the  diagnosis  of  certain  injuries  about  the 
hip.  McCurdy  prefers  a  line  drawn  from  the 
pubic  spine  ait  a  right  angle  to  the  median  line 
of  the  body ;  if  the  femur  is  normal  in  position 
the  pubic  line  should  cross  at  or  just  above  the 
great  trochanter.  The  mid-point  of  this  line  lies 
over  the  head  of  the  femur.  The  anterior  superior 
spine  or  crest  of  the  ilium  may  be  used  as  fixed 
points  from  which  to  estimate  the  degree  of  dis- 
placement of  the  great  trochanter. 

The  tubera  ischii  are  readily  felt.  They  are 
covered  by  the  fleshy  fibres  of  the  gluteus  maximus 
when  the  hip  is  extended.  But  when  the  hip  is 
flexed,  the  processes  become  to  a  great  extent  un- 
covered by  that  muscle.  The  muscular  mass  of 
the  buttock  is  formed  by  the  gluteus  maximus  be- 
hind and  by  the  gluteus  medius  and  minimus  and 
tensor  vaginae  femoris  in  front.  The  last-named 
muscle  can  be  seen  when  in  action,  i.e.  when  the 
thigh  is  abducted  and  rotated  in. 

The  fold  of  the  buttock  crosses  the  obliquely 
placed  lower  border  of  the  gluteus  maximus. 
When  the  hip  is  fully  extended,  as  in  the  erect 
posture,  the  buttocks  are  round  and  prominent, 
the  gluteal  fold  is  transverse  and  very  distinct. 
When  the  hip  is  a  little  flexed,  the  buttocks  be- 
come flattened,  the  gluteal  fold  becomes  oblique 
and  then  disappears.  Among  the  early  symptoms 
of  hip  disease  are  flattening  of  the  buttock  and 
loss  of  the  gluteal  fold.  These  symptoms  depend 
upon  the  flexion  of  the  hip,  which  is  practically 
constant  in  every  case  of  the  malady  before  treat- 
ment. It  is  incorrect  to  say,  as  some  books  still 
assert,  that  these  changes  are  due  to  wasting  of 
the  gluteal  muscles,  since  they  appear  at  too  early 
a  period  for  any  considerable  muscular  atrophy 
to  have  taken  place.  It  is  true  that  these  symp- 
toms are  much  exaggerated  by  the  wasting  of  the 


480  SUEGICAL    APPLIED    ANATOMY      [Part  V 

muscle  that  occurs  later  on  in  the  course  of  the 
hip  affection. 

With  regard  to  the  vessels  and  nerves  of  the 
buttock,  if  a  line  be  drawn  from  the  posterior 
superior  spine  to  the  top  of  the  great  trochanter 
when  the  thigh  is  rotated  in,  a  point  at  the  junc- 
tion of  the  inner  with  the  middle  third  of 
that  line  will  correspond  to  the  gluteal  artery 
as  it  emerges  from  the  sciatic  notch.  A  line 
drawn  from  the  posterior  superior  spine  to 
the  outer  part  of  the  tuber  ischii  crosses 
both  the  posterior  inferior  and  ischial  spines. 
The  former  is  about  2  inches  and  the  latter  about 
4  inches  below  the  posterior  superior  process.  The 
sciatic  artery  reaches  the  gluteal  region  at  a  spot 
corresponding  to  the  junction  of  the  middle  with 
the  lower  third  of  this  line.  The  position  of  the 
pudic  artery  as  regards  the  buttock  is  not  difficult 
to  indicate,  since  it  crosses  over  the  ischial  spine 
in  passing  from  the  great  to  the  small  sacro- 
sciatic  foramen.  The  sciatic  nerve  is  most  easily 
found  as  it  escapes  from  beneath  the  gluteus  maxi- 
mus.  When  the  thigh  is  rotated  outwards,  so  that 
the  great  trochanter  approaches  the  ischial  tuber- 
osity, the  nerve  lies  midway  between  these  two 
bony  points,  but  in  the  unrotated  position  it  is 
found  at  the  junction  of  the  inner  and  middle 
thirds  of  a  line  joining  them. 

The  skin  over  the  buttock  is  thick  and  coarse, 
and  is  frequently  the  seat  of  boils.  From  the 
appearance  it  presents  in  very  fully  injected  speci- 
mens, it  would  appear  that  the  blood  supply  is 
not  quite  so  free  as  it  is  in  many  other  parts  of 
the  surface. 

The  subcutaneous  fascia  is  lax,  and  contains 
a  large  quantity  of  fat.  It  is  to  this  fat  rather 
than  to  muscular  development  that  the  buttock 
owes  its  roundness  and  prominence.  The  enor- 
mous buttocks  of  the  so-called  "  Hottentot  Venus," 
whose  model  is  in  many  museums,  depend  for 
their  unusual  dimensions  upon  the  greatly  in- 
creased subcutaneous  fat.     The  amount  of  adipose 


Chap.  XIX]  REGION    OF    THE    HIP  481 

tissue  normally  in  the  part  renders  the  buttock 
a  favourite  place  for  lipomata.  The  laxity  of  the 
superficial  fascia  permits  large  effusions,  both  of 
blood  and  pus,  to  take  place  in  the  gluteal  region, 
and  ecchymoses  of  the  buttock  can  probably  reach 
a  greater  magnitude  than  is  possible  elsewhere. 

The  deep  fascia  of  the  buttock,  a  part  of 
the  fascia  lata  of  the  thigh,  is  a  structure  of  much 
importance.  This  dense  membrane  is  attached 
above  to  the  iliac  crest,  and  to  the  sacrum  and 
coccyx.  Descending  in  front  over  the  gluteus 
medius,  it  splits  on  reaching  the  anterior  edge  of 
the  gluteus  maximus  into  two  layers,  one  of  which 
passes  in  front  of  the  muscle  and  the  other  behind. 
The  gluteus  maximus  is  thus  enclosed,  like  the 
meat  in  a  sandwich,  between  two  layers  of  fascia, 
and  the  two  lesser  gluteal  muscles  are  bound  down 
within  an  osseo-aponeurotic  space,  which  is  firmly 
closed  above,  and  only  open^  below  towards  the 
thigh  and  internally  at  the  sciatic  foramina.  Ex- 
travasations of  blood  may  take  place  beneath  this 
fascia  without  any  discoloration  of  the  skin  to  in- 
dicate the  fact,  the  blood  being  unable  to  reach 
the  surface  through  the  dense  membrane.  Such 
extravasations  may  be  long  pent  up,  and,  as  they 
fluctuate^  may  be  mistaken  for  abscess. 

Deep  inflammations  beneath  this  fascia,  and 
especially  when  beneath  the  gluteus  medius,  may 
be  associated  with  much  pain,  owing  to  the  cir- 
cumstance that  the  inflammatory  effusions^  will  be 
pent  up  between  a  wall  of  bone  on  one  side  and 
a  wall  of  dense  fascia  and  stout  muscle  on  the 
other.  Abscesses  so  pent  up  may  travel  for  a  con- 
siderable distance  down  the  thigh  before  they 
reach  the  surface,  and  Farabeuf  relates  a  case 
where  a  gluteal  abscess  travelled  to  the  ankle 
before  it  broke. 

Under  other  circumstances  the  gluteal  abscess 
may  make  its  way  into  the  pelvis  through  the 
sciatic  foramina,  or  a  pelvic  abscess  may  escape 
through  one  of  these  foramina  and  appear  as  a 
deep  abscess  of  the  buttock. 
2F 


482  SUEGICAL   APPLIED   ANATOMY      [Part  V 

The  thickened  part  of  the  fascia  lata  that  runs 
down  on  the  outer  side  of  the  limb  between  the 
crest  of  the  ileum  above  and  the  outer  tuberosity 
of  the  tibia  and  head  of  the  fibula  below,  is 
known  as  the  ilio-tibial  band.  This  band  is  tightly 
stretched  across  the  gap  between  the  iliac  crest 
and  the  great  trochanter,  and  if  pressure  be  made 
with  the  fingers  between  these  two  points,  the  re- 
sistance of  this  part  of  the  fascia  can  be  appreci- 
ated. It  is  obvious  that  in  fracture  of  the  neck 
of  the  femur,  when  the  great  trochanter  is  made 
to  approach  nearer  to  the  crest,  this  band  will 
become  relaxed,  and  Dr.  Allis  (Agnew's  "  Sur- 
gery/' vol.  i.)  has  drawn  attention  to  this  fascial 
relaxation  as  of  value  in  the  diagnosis  of  frac- 
tures of  the  femoral  neck. 

The  lower  free  edge  of  the  gluteus  inaximus 
is  oblique,  and  ends  some  way  below  the  transverse 
line  of  the  fold  of  the  buttock. 

It  would  appear  that  even  this  great  muscle 
may  be  ruptured  by  violence.  Thus  Dr.  Mac- 
Donnell  (Brit.  Med.  Journ.,^  1878)  reports  the  case 
of  a  robust  man,  aged  sixty-three  who,  while 
trying  to  lift  a  heavy  cart  when  in  a  crouching 
position,  felt  something  give  way  in  his  buttock, 
and  heard  a  snap.  He  fell,  and  was  carried  home, 
when  it  was  found  that  the  great  gluteal  muscle 
was  ruptured  near  the  junction  of  the  muscle  with 
its  tendon. 

At  least  three  bursae  exist  over  the  great 
trochanter,  separating  that  process  from  the  three 
gluteal  muscles  respectively.  The  most  extensive 
is  that  between  the  insertion  of  the  gluteus  maxi- 
mus  to  the  ilio-tibial  band  and  outer  surface  of 
the  great  trochanter.  The  bursa  allows  the  great 
trochanter  to  move  freely  beneath  the  muscle 
during  rotation  of  the  thigh.  When  this  sac  is 
inflamed  much  difficulty  is  experienced  in  moving 
the  limb,  and  the  thigh  is  generally  kept  flexed 
and  adducted.  This  position  means  absolute  rest 
from  movement  on  the  part  of  the  gluteal  muscles, 
which,    when    acting,    would   extend   and   abduct 


Chap.  XIX]  REGION    OF   THE   HIP  483 

the  limb,  and  bring  pressure  to  bear  upon  the 
tender  bursa. 

There  is  a  bursa  over  the  ischial  tuberosity 
that  is  often  inflamed  in  those  whose  employments 
involve  much  sitting,  the  bursa  being  directly 
pressed  upon  in  that  position.  This  sac  is  the 
anatomical  basis  of  the  disease  known  in  older 
text-books  as  "weaver's  bottom"  or  "lighter- 
man's bottom."  When  enlarged  this  bursa  may 
press  upon  the  inferior  pudendal  nerve. 

The  arteries  and  nerves  of  the  buttock. — 
The  gluteal  artery  is  about  the  same  size  as  the 
ulnar,  and  the  sciatic  as  the  lingual.  The 
former  vessel  may  sometimes  be  of  much  greater 
magnitude,  and  has  led,  when  wounded,  to  rapid 
death  from  haemorrhage.  Wounds  of  the  gluteal 
vessels  will  probablv  involve  only  the  branches  of 
the  artery,  since  #  the  greater  part  of  the  main 
trunk  is  situate  within  the  pelvis.  Gluteal  aneur- 
isms are  not  very  uncommon,  and  with  regard  to 
the  treatment  of  these  tumours  it  may  be  noted 
that  the  gluteal  artery,  or,  better,  the  internal 
iliac  trunk,  can  be  compressed  through  the  rectum. 
Compression  so  applied  has  been  adopted  for  the 
treatment  of  gluteal  aneurism  by  Dr.  Sands,  of 
New  York  (Amer.  Journ.  Med.  Sc,  1881),  but 
without  much  effect.  Aneurism  of  the  commence- 
ment of  the  gluteal  artery  could  hardly  fail  to 
provoke  nerve  symptoms,  since  the  vessel  runs  be- 
tween the  lumbo-sacral  cord  and  first  sacral  nerve. 

Both  the  gluteal  and  sciatic  arteries  have  been 
ligatured  in  the  buttock,  through  incisions  made 
directly  over  the  course  of  the  vessels. 

Henle  has  collected  six  cases  where  the  femoral 
artery  ran  down  along  the  back  of  the  thigh  to 
the  "Dopliteal  snace  in  company  with  the  great 
sciatic  nerve.  The  abnormal  vessel  was  in  each 
case  formed  by  an  enlargement  of  the  comes  nervi 
ischiadici,  a  branch  of  the  sciatic  artery. 

The  great  sciatic  nerve  is  a  continuation 
downwards  of  the  main  part  of  the  sacral  plexus. 
It  is  in  this  nerve  that  the  form  of  neuralgia 


484  SUEGICAL   APPLIED    ANATOMY      [Part  V 

known  as  sciatica  is  located.  A  reference  to  the 
immediate  relations  of  this  nerve  will  show  that 
it  may  readily  be  exposed  to  many  external  in- 
fluences. Thus,  in  the  pelvis  it  may  be  pressed 
upon  by  various  forms  of  pelvic  tumour,  and 
sciatica  be  produced  in  consequence.  Its  anterior 
surface  is  in  close  relation  with  some  of  the  princi- 
pal pelvic  veins,  and  according  to  Erb  one  form 
of  sciatica  may  be  traced  to  an  engorged  condi- 
tion of  these  vessels.  Aneurism  of  certain  branches 
of  the  internal  iliac  artery  within  the  pelvis, 
sciatic  hernia,  and  accumulation  of  faeces  within 
the  rectum,  may  all  cause  neuralgia '  of  this  im- 
portant trunk.  It  is  said  to  have  been  injured 
also  by  the  pressure  of  the  foetal  head  during 
tedious  labours,  and  to  be  affected  by  violent 
movements  of  the  hip,  a  circumstance  readily 
understood  if  the  close  relation  of  the  nerve  to 
the  hip-joint  be  borne  in  mind.  The  nerve  is  also 
near  enough  to  the  surface  to  be  influenced  by 
external  cold,  and  to  this  influence  many  forms 
of  sciatica  are.  ascribed.  At  the  lower  edge  of 
the  great  gluteal  muscle  the  trunk  is  still  nearer 
to  the  surface,  and  this  fact  receives  illustration 
in  a  case  reported  in  Ziemssen's  Cyclopaedia, 
where  paralysis  of  the  nerve  followed  its  com- 
pression by  the  contracting  scar  of  a  bed:sore. 

Nerve  stretching-.  —  The  great  sciatic  nerve 
has  been  frequently  cut  down  upon  and  stretched 
for  the  relief  of  certain  nervous  affections  of  the 
limb  (see  rj.  480).  In  connection  with  this  pro- 
cedure it  is  important  to  know  how  great  an 
amount  of  traction  may  be  brought  to  bear  upon 
this  and  other  nerves  without  the  cord  giving  way. 
Trombetta,  who  has  paid  much  attention  to  this 
matter,  gives  the  following  weights  as  those  re- 
quired fa>  ^  break  the  undermentioned  nerves  : 
great  sciatic,  183  pounds;  internal  popliteal,  114 
pounds ;  anterior  crural,  83  pounds ;  median,  83 
pounds;  ulnar  and  radial,  59  pounds;  brachial 
plexus  in  the  neck.  48  to  63  pounds;  and  brachial 
plexus  in  the  axilla,  35  to  81  pounds.     (In  each 


Ohap.  XIX]  REGION    OF   THE   HIP  485 

instance  fractions  have  been  omitted.)  It  must 
be  borne  in  mind,  however,  as  pointed  out  by  Mr. 
Symington  {Lancet,  1S78),  that  in  forcibly  stretch- 
ing the  great  sciatic  nerve  the  trunk  may  be  torn 
away  from  its  attachments  to  the  soft  spinal  cord 
before  a  sufficient  force  has  been  applied  to  rup- 
ture the  nerve  at  the  point  stretched.  The  same 
observation  applies  to  other  large  nerve-cords, 
such  as  those  of  the  brachial  plexus,  that  are 
stretched  at  a  spot  not  far  from  their  spinal  con- 
nections. The  great  sciatic  nerve  may  be  stretched 
by  flexing  the  extended  lower  extremity  on  the 
belly.  This  measure  "has  served  to  cure  certain 
cases  of  sciatica. 

The  skin  of  the  buttock  is  well  supplied  with 
nerves,  and  tactile  sensibility  is  almost  as  acute 
in  this  part  as  it  is  over  the  back  of  the  hand, 
while  it  is  more  acute  than  is  like  sensibility 
in  such  parts  as  the  back  of  the  neck,  the  middle 
of  the  thigh,  and  the  middle  of  the  back.  The 
sensation  of  the  gluteal  integument  is  derived 
from  a  number  of  different  nerves,  and  it  may 
possibly  interest  a  school-boy  who  has  been^  re- 
cently birched  to  know  that  the  painful  sensations 
reached  his  sensorium  through  some  or  all  of  the 
following  nerves  :  offsets  of  the  posterior  branches 
of  the  lumbar  nerves,  some  branches  of  the  sacral 
nerves,  the  lateral  cutaneous  branch  of  the  last 
dorsal  nerve,  the  iliac  branch  of  the  ilio-hypo- 
gastric  nerve,  offsets  of  the  external  cutaneous 
nerve,  and  large  branches  of  the  small  sciatic. 
These  nerves  are  derived  from  four  spinal  seg- 
ments— the  twelfth  dorsal,  first  lumbar,  second 
and  third  sacral  (Fig.  105,  p.  597).  The  second 
and  third  sacral  also  supply  the  sexual  organs, 
hence  the  physiological  effects  which  may  follow 
application  of  punishment  to  this  part,  as  in  the 
celebrated  case  of  J.  J.  Rousseau. 

It  should  be  remembered  that  the  pelvic  vis- 
cera can  be  readily  reached  through  the  sciatic 
foramina  from  the  buttock.  I  once  saw  a  case  at 
the  London  Hospital  of  a  man  who  was  admitted 


486  SUEGICAL   APPLIED    ANATOMY     [Part  V 

with  an  apparently  insignificant  stab  of  the  but- 
tock. He  died  in  a  few  days,  of  acute  peritonitis; 
and  the  autopsy  showed  that  the  dagger  had 
passed  througn  the  great  sacro-sciatic  foramen, 
had  entered  the  bladder  and  allowed  urine  to 
escape  into  the  peritoneal  cavity.  The  rectum 
has  also  been  damaged  in  injuries  to  the  buttock, 
and  Anger  records  a  case  of  an  artificial  anus 
situate  upon  the  buttock,  that  had  followed  a  gun- 
shot wound,  which,  after  involving  the  buttock, 
had  opened  up  the  csecum.  It  is  by  this  route  that 
Kraske's  operation  for  resection  of  the  rectum 
is  performed  and  Rigby's  operation  on  the  ureter. 

2.  The  region  of  Scarpa's  triangle.  — 
Surface  anatomy.  The  most  important  land- 
marks in  the  region  of  the  groin,  the  anterior 
superior  iliac  spine,  the  spine  of  the  pubes,  and 
Poupart's  ligament,  are  readily  made  out.  To 
the  two  spines  reference  has  already  been  made 
(p.  322).  Poupart's  ligament  follows  a  curved 
line,  with  its  convexity  downwards,  drawn  be- 
tween these  two  projections.  It  can  be  felt  in 
even  stout  persons,  its  inner  half  more  distinctly 
than  its  outer,  and  even  in  very  fat  individualsits 
position  is  indicated  by  a  slight  furrow.  Owing 
to  its  attachment  to  the  fascia  lata  the  ligament 
is  relaxed,  and  rendered  less  distinct  when  the 
thigh  is  flexed  and  adducted,  or  when  it  is  rotated 
in.  The  mid-point  of  a  line  joining  the  pubic 
with  the  anterior  superior  spine  lies  over  the 
head  of  the  femur  and  hip  joint.  In  this  position 
a  crease  is  often  to  be  seen  crossing  the  groin 
(Holden). 

The  sartorius  muscle  is  brought  into  view  when 
the  leg  is  raised  across  the  opposite  knee,  and  the 
adductor  longus  is  rendered  distinct  when  the 
thigh  is  abducted,  and  the  individual's  attempts 
to  adduct  the  limb  are  resisted.  Even  in  the 
obese  the  edge  of  this  muscle  can  be  felt  when 
it  is  in  vigorous  action,  and  the  fingers  can 
follow  its  border  up  to  the  very  origin  of  the 
muscle,   just  below  the  pubic  spine. 


Chap.  XIX]  EEGION    OF   THE   HIP  48? 

The  lymphatic  glands  in  this  region  can  some- 
times be  felt  beneath  the  skin,  especially  in  thin 
children.  The  femoral  ring  lies  behind  Poupart's 
ligament  1  inch  externally  to  the  pubic  spine  (Fig. 
57,  p.  340).  The  position  of  the  saphenous  open- 
ing is  sometimes  indicated  by  a  slight  depression 
in  the  integuments.  It  lies  just  below  Poupart's 
ligament,  and  its  centre  is  about  li  inch  below 
and  external  to  the  pubic  spine.  In  thin  sub- 
jects the  long  saphenous  vein  can  be  often  made 
out,  passing  to  the  saphenous  opening. 

If  a  line  be  drawn  from  the  femoral  point 
(Fig.  57,  p.  340)  to  the  tubercle  for  the  adductor 
magnus,  on  the  inner  condyle  of  the  femur,  when 
the  thigh  is  slightly  flexed  and  abducted,  it  will 
correspond  in  the  upper  two-thirds  of  its  extent 
to  the  position  of  the  femoral  artery.  Just  below 
Poupart's  ligament  the  femoral  vein  lies  to  the 
inner  side  of  the  artery,  while  the  anterior  crural 
nerve  runs  about  \  of  an  inch  to  its  outer  side. 
The  profunda  femoris  arises  about  li  inch  below 
Poupart's  ligament,  and  the  internal  and  ex- 
ternal circumflex  vessels  come  off  about  2  inches 
below  that  structure. 

The  skin  over  Scarpa's  triangle  is,  unlike  that 
of  the  buttock,  comparatively  thin  and  fine.  The 
looseness  of  its  attachment,  also.,  to  the  parts  im- 
mediately beneath,  permits  it  to  be  greatly 
stretched,  as  is  seen  in  cases  of  large  femoral 
hernise,  and  in  certain  inguinal  tumours  of  large 
size.  It  may  even  give  way  under  severe  traction, 
as  occurred  in  a  case  reported  by  Berne.  The 
patient  in  this  case  was  a  child  aged  11,  the  sub- 
ject of  hip  disease.  The  thighs  were  flexed  upon 
the  abdomen,  and,  forcible  extension  being  ap- 
plied to  relieve  the  deformity,  the  skin  gave  way 
just  below  the  groin,  and  separated  to  the  extent 
of  some  2^  inches.  Contracting  scars  in  the  region 
of  the  groin  may  produce  a  permanent  flexing  of 
the  hip,  and  this  result  is  not  uncommon  after 
deep  and  severe  burns  in  this  neighbourhood.  It 
may   at  the  same  time  be   noted  that  horizontal 


488  SUEGICAL    APPLIED    ANATOMY      [Part  V 

wounds  about  the  groin  can  be  well  adjusted  by 
a  slight  flexion  of  the  thigh. 

Instances  are  recorded  where  a  supernumerary 
mammary  gland,  provided  with  a  proper  nipple, 
has  been  found  located  in  the  groin.  Jessieu 
relates  the  case  of  a  female  who  had  a  breast  so 
placed,  and  who  suckled  her  child  from  this 
part  (see  p.  205).  In  a  few  cases  the  testicle,  in- 
stead of  descending  into  the  scrotum,  has  escaped 
through  the  crural  canal,  and  made  its  appear- 
ance in  Scarpa's  triangle.  It  has  even  mounted 
up  over  Poupart's  ligament  after  the  manner  of  a 
femoral  hernia,  being  probably  urged  in  that 
direction  by  the  movements  of  the  limb.  > 

The  superficial  fascia  in  this  region  is  not 
very  dense,  and  has  little  or  no  influence  upon 
the  progress  of  a  superficial  abscess.  This  fact 
receives  extensive  illustration,  since  the  glands  in 
Scarpa's  triangle  frequently  suppurate,  and  yet 
the  pus  in  the  great  majority  of  cases  readily 
reaches  the  surface  in  spite  of  the  circumstance 
that  the  denser  layer  of  the  superficial  fascia  (for 
in  this  region  it  is  divided  into  two  layers)  covers 
in  those  glands,  and  should  hinder  the  progress 
of  pus  towards  the  surface.  Although  the  sub- 
cutaneous fat  is  not  peculiarly  plentiful  in  this 
region,  yet  Scarpa's  triangle  is  a  favourite  spot 
for  lipomata.  It  is  in  this  place  that  the  fatty 
tumour  often  exhibits  its  disposition  to  travel, 
and  several  cases  are  reported  where  such  a 
tumour  has  started  at  the  groin  and  travelled 
some  way  down  the  thigh.  The  journey  is  always 
in  the  direction  of  gravity,  and  rendered  possible 
by  the  lax  capsule  of  the  tumour,  by  the  loose- 
ness of  the  tissue  in  which  it  is  embedded,  and  by 
the  fluidity  of  fat  at  the  normal  temperature  of 
the  body. 

The  fascia  lata  completely  invests  the  limb, 
being,  so  far  as  the  front  of  the  thigh  is  con- 
cerned, attached  above  to  Poupart's  ligament,  to 
the  body  and  ramus  of  the  pubes,  and  the  ramus 
of  the  ischium.     Its  integrity  is  interrupted  only 


Chap.  XIX]  REGION    OF    THE    HIP  489 

by  the  saphenous  opening.  This  fascia  exercises 
some  influence  upon  deep  abscesses  and  deep 
growths.  Thus  a  psoas  abscess  reaches  the  thigh 
by  following  the  substance  of  the  psoas  muscle, 
and  finds  itself,  when  it  arrives  at  Scarpa's  tri- 
angle, under  the  fascia  lata.  In  a  great  number 
of  cases  it  points  where  the  psoas  muscle  ends, 
but  in  other  and  less  frequent  instances  its  pro- 
gress is  decidedly  influenced  by  the  fascia  lata, 
and  it  moves  down  the  limb.  Thus  guided,  a 
psoas  abscess  has  pointed  low  down  in  the  thigh, 
and  even  at  the  knee,  and  Erichsen  reports  a  case 
where  such  an  abscess  (commencing,  as  it  did,  in 
the  dorsal  spine)  was  ultimately  opened  by  the 
side  of  tne  tendo  Achillis. 

The  ilio-psoas  muscle,  being  stretched,  as  it 
were,  over  the  front  of  the  hip-joint,  and  partici- 
pating in  many  of  the  movements  of  that  joint, 
is  peculiarly  liable  to  be  sprained  in  violent  exer- 
cises. Between  this  muscle  and  the  thinnest  part 
of  the  hip  capsule  is  a  bursa,  which  not  unfre- 
quently  communicates  with  the  joint.  When 
chronically  inflamed,  this  bursa  may  form  a  large 
tumour  on  the  front  of  the  thigh  that  may,  ac- 
cording to  Nancrede,  attain  the  size  of  a  child's 
head.  To  relieve  this  bursa  from  pressure  when 
inflamed,  the  thigh  always  becomes  flexed,  and  a 
train  of  symptoms  is  produced  that  are  not  unlike 
those  of  hip  disease.  The  deep  origins  of  the  ilio- 
psoas lie  behind  the  caecum  and  kidney,  and  may 
elicit  symptoms  from  those  organs  when  con- 
tracted. 

The  sartorius  is  a  muscle  that,  from  its  length, 
peculiar  action,  etc.,  one  would  hardly  expect  to 
find  ruptured  from  violence,  yet  in  the  Musee 
Dupuytren  there  is  a  specimen  of  such  a  rupture 
about  the  middle  of  the  muscle  united  by  fibrous 
tissue.  The  adductor  muscles,  and  especially  the 
adductor  longus,  are  frequently  sprained,  or  even 
partially  ruptured,  during  horse  exercise,  the  grip 
of  the  saddle  being  for  the  most  part  maintained 
by   them.     "  Rider's   sprains,"    as   such   accidents 


490  SURGICAL   APPLIED   ANATOMY     [Part  V 

are  called,  usually  involve  the  muscles  close  to 
their  pelvic  attachments.  Much  blood  is  often 
effused  when  the  fibres  are  ruptured,  and  such 
effusion  may  become  so  dense  and  fibrinous  as  to 
form  a  mass  that  has  been  mistaken  for  a  detached 
piece  of  the  pubes  (Henry  Morris).  The  term 
''  rider;s  bone  ;;  refers  to  an  ossification  of  the 
upper  tendon  of  the  adductor  longus  or  magnus, 
following  a  sprain  or  partial  rupture.  Cases  are 
reported  where  the  piece  of  bone  in  the  tendon 
was  \  an  inch,  2  inches,  and  even  3  inches  long. 

Blood-vessels. — The  femoral  artery  occupies 
so  superficial  a  position  in  Scarpa's  triangle  that 
it  is  not  unfrequently  wounded.  The  vessel  also 
has  been  opened  up  by  cancerous  and  phagedenic 
ulcerations  of  this  part,  the  occurrence  leading  to 
fatal  haemorrhage.  Pressure  is  most  conveniently 
applied  to  the  artery  at  a  spot  immediately  below 
Poupart's  ligament,  and  should  be  directed  back- 
wards, so  as  to  compress  the  vessel  against  the 
pubes  and  adjacent  parts  of  the  hip  capsule. 
Lower  down,  compression  should  be  applied  in  a 
direction  backwards  and  outwards,  so  as  to  bring 
the  artery  against  the  shaft  of  the  femur,  which 
lies  at  some  distance  to  its  outer  side.  Pressure 
rudely  applied  by  a  tourniquet  may  cause  phle- 
bitis by  damaging  the  vein,  or  neuralgia  by  con- 
tusing the  anterior  crural  nerve. 

From  the  proximity  of  the  artery  and  vein, 
it  happens  that  arterio-venous  aneurisms  follow- 
ing wounds  have  been  met  with  in  this  situa- 
tion. Aneurism  is  frequent  in  the  common 
femoral,  and  many  reasons  can  be  given  why  that 
vessel  should  be  attacked.  It  is  just  about  to 
bifurcate  into  two  large  trunks,  its  superficial 
position  exposes  it  to  injury,  it  is  greatly  influ- 
enced by  the  movements  of  the  hip,  and  its  coat 
may,  if  diseased,  be  damaged  by  those  movements, 
if  excessive. 

Phlebitis  of  the  femoral  vein  has  in  many  cases 
followed  contusion  of  the  vessel  in  its  upper  or 
more  superficial  part,  and  a  like  result  has  even 


Chap.  XIX]  REGION    OF   THE   HIP  491 

followed  from  violent  flexion  of  the  thigh.  The 
long  saphenous  vein  is  often  varicose,  and  one 
form  of  the  varicosity  is  said  to  depend  upon  con- 
striction of  the  vein  by  an  unduly  narrow  saphen- 
ous opening.  That  varicose  veins  are,  m  the 
majority  o±  cases,  of  congenital  origin  is  now 
very  generally  allowed. 

The  anterior  crural  nerve  lies  on  the  ilio- 
psoas muscle,  and  it  is  said  that  neuralgia,  and 
even  paralysis  of  the  nerve,  may  follow  upon  in- 
flammation of  that  muscle  and  upon  psoas  abscess. 
The  superficial  position  of  the  trunk  exposes  it  to 
injury.  The  genito-crural  nerve  (the  nerve  that 
supplies  the  cremaster  muscle)  gives  a  sensory  fila- 
ment to  the  integument  of  the  thigh  in  Scarpa's 
triangle.  Irritation  of  the  skin  over  the  seatof 
this  nerve,  which  is  placed  just  to  the  outer  side 
of  the  femoral  artery,  will  cause,  in  children,  a 
sudden  retraction  of  the  testicle.  The  same  result 
is  often  seen  in  adults,  also,  on  more  severe  stimu- 
lation. In  this  manner  the  condition  of  the  second 
lumbar  segment  of  the  cord  may  be  tested. 

The  lymphatic  glands  in  this  region  are 
numerous,  and  as  they  are  frequently  the  seat  of 
abscess,  it  is  important  to  know  from  whence  they 
derive  their  afferent  vessels.  They  are  divided 
into  a  superficial  and  a  deep  set.  The  superficial 
set,  averaging  from  ten  to  fifteen  glands,  is  ar- 
ranged in  two  groups,  one  parallel  and  close  to 
Poupart's  ligament  (the  horizontal  series),  the 
other  parallel  and  close  to  the  long  saphenous  vein 
(the  vertical  series).  The  deep  set,  about  four  in 
number,  are  placed  along  the  femoral  vein,  and 
reach  the  crural  canal. 

The  inguinal  glands  receive  the  following  lym- 
phatics : 

Superficial  vessels  of  lower  limb  =  vertical  set 
of  superficial  glands. 

Superficial  vessels  of  lower  half  of  abdomen  = 
middle  glands  of  horizontal  set. 

Superficial  vessels  from  outer  surface  of  but- 
tock =  external  glands  of  horizontal  set. 


492  SUEGICAL   APPLIED    ANATOMY     [Part  V 

From  inner  surface  of  buttock  =  internal 
glands  of  horizontal  set.  (A  few  of  these  vessels 
go  to  the  vertical  glands.) 

Superficial  vessels  from  external  genitals  = 
horizontal  glands,  some  few  going  to  vertical  set. 

Superficial  vessels  of  perineum  and  anus  = 
vertical  set. 

Deep  lymphatics  of  lower  limb  =  deep  set  of 
glands. 

The  lymphatics  that  accompany  the  obturator, 
gluteal,  and  sciatic  arteries,  and  the  deep  vessels 
of  the  penis,  pass  to  the  pelvis  and  have  no  con- 
nection with  the  inguinal  glands.  The  only  super- 
ficial lymphatics  of  the  lower  extremity  which  do 
not  pass  direct  to  the  inguinal  glands  are  those 
which  drain  the  outer  side  of  the  ankle  and  pos- 
terior aspect  of  the  leg.  The  vessels  from  these 
areas  accompany  the  short  saphenous  vein  and 
end  in  the  popliteal  glands ;  the  efferent  vessels 
from  these  glands  pass  to  the  deep  inguinal  set. 

One  of  the  deep  glands  lies  in  the  crural  canal 
and  upon  the  septum  crurale.  Being  surrounded 
by  dense  structures,  it  is  apt  to  cause  great  dis- 
tress when  inflamed  and  great  pain  when  the  hip 
is  moved.  In  some  cases,  by  reflex  disturbance, 
it  has  produced  symptoms  akin  to  those  of 
strangulated  hernia.  Some  branches  of  the  an- 
terior crural  nerve  lie  over  the  inguinal  lymph 
glands,  and  Sir  B.  Brodie  reports  a  case  in  which 
these  branches  were  stretched  over  two  enlarged 
glands,  like  strings  of  a  violin  over  its  bridge, 
so  that  violent  pain  and  convulsive  movements 
were  set  up  in  the  limb. 

The  efferent  vessels  from  the  inguinal  glands 
Dass  through  a  chain  of  lymphatic  glands  stretch- 
ing along  the  course  of  the  external  and  common 
iliac  vessels.  Three  of  these  glands  lie  imme- 
diately above  Poupart's  ligament.  The  efferent 
vessels  of  the  internal  iliac  group  of  glands,  into 
which  the  pelvic  lymphatics  drain,  join  the  chain 
along  the  common  iliac  vessels.  The  lumbar 
glands  receive  the   lymph   from  the  iliac  groups 


Chap.  XIX]  EEGION    OF   THE   HIP 


493 


and  pass  it  on  by  the  right  and  left  lumbar  trunks 
to  the  receptaculum  chyli. 

Elephantiasis  Arabum  is  more  common  in  the 


Fig.  76. — Vertical  section  of  the  upper  third  of  the  thigh  showing  the 
structures  in  relationship  with  the  hip-joint.    {After  Braune.)  " 

Muscles.— 1,  psoas  ;  2,  iliaeus  ;  3,  gluteus  medius ;  4,  glutens  minimus  ;  5,  obturator 
interims  ;  6,  obturator  externus  ;  7,  ilio-psoas  ;  8,  pectineus ;  9,  adductor 
magnus ;  10,  adductor  brevis ;  11,  gracilis  ;  12.  adductor  tongus  ;  13,  vastus 
intemus  ;  14,  vastus  externus.  a,  anterior  crural  nerve  ;  b,  external  iliac, 
artery;  c.  external  iliac  vein;  d,  obturator  nerve;  e,  obturator  artery; 
/,  branches  of  obturator  vessels  to  hip-joint ;  g,  internal  circumflex  vessels  ; 
'/(,  deep  femoral  vessels:  i,  branch  of  external  circumflex  ;  j,  bursa  over  sreat 
i  rochanter ;  k,  reflections  of  capsule  to  neck  of  femur ;  m,  asc.  ramus  of  pubes  ; 
v,  peritoneum  ;  o,  iliac  fascia. 

lower  limb  than  in  any  other  part,  and  leads  to  an 
enormous  increase  in  the  size  of  the  extremity 
(Cochin  or  Barbadoes  leg).  Its  pathology  is  in- 
timately concerned  with  the  crural  lymphatics. 
The  lymphatics  are  obstructed  by  a  small  thread- 


494  SUEGICAL   APPLIED    ANATOMY      [Part  V 

worm,  Filaria  sanguinis  hominis.  The  lymph  ves- 
sels and  lymph  spaces  in  the  connective  tissue  be- 
come greatly  distended,  and  the  elements  of  the 
connective  tissue  hypertrophied. 

The  hip-joint.— The  hip-joint  is  an  articula- 
tion of  considerable  strength  (Fig.  76).  This 
strength  depends  not  only  upon  the  shape  of  the 
articulating  bones,  which  permits  of  a  good  ball- 
and-socket  joint  being  formed,  but  also  upon  the 
powerful  ligaments  that  connect  them  and  the 
muscular  bands  that  directly  support  the  capsule. 
These  advantages,  however,  are  to  some  extent 
counterbalanced  by  the  immense  leverage  that  can 
be  brought  to  bear  upon  the  femur,  and  the 
numerous  strains  and  injuries  to  which  the  joint 
is  subjected,  as  the  sole  connecting  link  between 
the  trunk  and  the  lower  limb. 

The  acetabulum  is  divided  into  an  articular 
and  a  non-articular  part.  The  former  is  of 
horse-shoe  shape,  and  varies  from  1  inch  to  \  an 
inch  in  width.  The  bone  immediately  above  the 
articular  area  is  very  dense,  and  through  it  is 
transmitted  the  superincumbent  weight  of  the 
trunk.  The  non-articular  part  corresponds  to  the 
area  enclosed  by  the  horse-shoe,  and  is  made  up 
of  very  thin  bone.  In  spite  of  its  thinness  it  is 
very  rarely  fractured  by  any  violence  that  may 
drive  the  femur  up  against  the  pelvic  bones,  since 
no  ordinary  force  can  bring  the  head  of  the  thigh- 
bone in  contact  with  this  segment  of  the  os  in- 
nominatum. 

Pelvic  abscesses  sometimes  make  their  way  into 
the  hip-joint  through  the  non-articular  part  of  the 
acetabulum,  and  an  abscess  in  the  hip-joint  may 
reach  the  pelvis  by  the  same  route.  But  both 
such  circumstances  are  rare.  In  some  cases  of 
destructive  hip  disease  the  acetabulum  may  separ- 
ate into  its  three  component  parts.  Up  to  the  age 
of  puberty  these  three  bones  are  separated  by  the 
Y-shaped  cartilage.  At  puberty  the  cartilage  be- 
gins to  ossify,  and  by  the  eighteenth  year  the 
acetabulum  is  one  continuous  mass  of  bone.     The 


Chap.  XIX]  REGION    OF   THE   HIP  495 

breaking  up  of  the  acetabulum  by  disease,  there- 
fore, is  only  possible  before  that  year. 

The  manner  in  which  the  various  movements  at 
the  hip  are  limited  may  be  briefly  expressed  as 
follows.  Flexion,  when  the  knee  is  bent,  is  limited 
by  the  contact  of  the  soft  parts  of  the  groin,  and 
by  some  part  of  the  ischio-femoral  ligament;  when 
the  knee  is  extended  the  movement  is  limited  by 
the  hamstring  muscles.  Extension  is  limited  by 
the  ilio-femoral  or  Y  ligament.  Abduction,  by  the 
pubo-femoral  ligament.  Adduction  of  the  flexed 
limb  is  limited  by  the  ligamentum  teres  and  ischio- 
femoral ligament,  and  of  the  extended  limb  by 
the  outer  fibres  of  the  ilio-femoral  ligament  and 
upper  part  of  the  capsule.  Rotation  outwards  is 
resisted  by  the  ilio-femoral  ligament,  and  especi- 
ally by  its  inner  part,  during  extension,  and  by 
the  outer  limb  of  that  ligament  and  the  liga- 
mentum teres  during  flexion.  Rotation  inwards 
is  limited  during  extension  by  the  ilio-femoral 
ligament,  and  during  flexion  by  the  ischio-femoral 
ligament  and  inner  part  of  the  capsule.  The 
structures  which  take  the  chief  part  in  maintain- 
ing the  integrity  of  the  joint,  however,  are  not 
the  ligaments  but  the  strong  muscles  which  sur- 
round and  act  on  the  joint.  Atmospheric  pres- 
sure takes  no  part,  for  the  fat  at  the  transverse 
notch  is  readily  drawn  into  the  acetabulum  to 
make  good  any  space  vacated  by  the  femoral  head 
in  all  normal  movements  of  the  hip-joint. 

Hip-joint  disease—Owing  to  its  deep  posi- 
tion and  its  thick  covering  of  soft  parts  (Fig.  76), 
this  articulation  is  able  to  escape,  to  a  great  ex- 
tent, those  severer  injuries  that  are  capable  of 
producing  aciite^  inflammation  in  other  joints. 
Acute  synovitis  is  indeed  auite  rare  in  the  hip, 
and  the  ordinary  disease  of  the  part  is  of  a  dis- 
tinctlv  chronic  character.  It  follows,  also,  from 
the  deep^  position  of  the  articulation  that  pus, 
when  it  is  formed  in  connection  with  disease,  re- 
mains pent  up,  and  is  long  before  it  reaches  the 
surface.     Suppuration   in  this  region,   therefore, 


496  SUEGICAL   APPLIED    ANATOMY      [Part  V 

is  often  very  destructive.  When  effusion  takes 
place  into  the  joint,  the  swelling  incident  thereto 
will  first  show  itself  in  those  parts  where  the  hip 
capsule  is  the  most  thin.  The  thinnest  parts  of  the 
capsule  are  in  front  and  behind;  in  front,  in  the 
triangular  interval  between  the  inner  edge  of  the 
Y  ligament  and  the  pubo-femoral  ligament,  and 
behind  at  the  posterior  and  lower  part  of  the 
capsule.  It  is  over  these  two  districts  that  the 
swelling  first  declares  itself  in  cases  of  effusion 
into  the  joint,  and  as  these  parts  are  readily  ac- 
cessible to  pressure,  it  follows  that  they  corre- 
spond also  to  the  regions  where  tenderness  is  most 
marked  and  is  earliest  detected. 

In  chronic  hip  disease,  certain  false  positions 
are  assumed  by  the  affected  limb,  the  meaning  of 
which  it  is  important  to  appreciate.  These  posi- 
tions may  be  arranged  as  follows,  according,  as 
nearly  as  possible,  to  their  order  of  appearing  : 

(1)  The  thigh  is  flexed,  abducted,  and  a  little 
everted ;  and  associated  with  this  there  is  (2) 
apparent  lengthening  of  the  limb  and  (3)  lordosis 
of  the  spine ;  (4)  the  thigh  is  adducted  and  in- 
verted, and  incident  to  this  there  is  (5)  apparent 
shortening  of  the  limb ;  (6)  there  is  real  shorten- 
ing of  the  limb. 

(1).  The  first  position  is  simply  the  posture  of 
greatest  ease.  It  depends^  mainly  upon  the  ef- 
fusion into  the  joint.  If  fluid  be  forcibly  injected 
into  a  hip-joint  the  thigh  becomes  flexed,  abducted, 
and  a  little  everted.  In  other  words,  the  articula- 
tion holds  the  most  fluid  when  the  limb  is  in  this 
position,  and  the  patient  places  it  there  to  relieve 
pain  by  reducing  the  tension  within  the  capsule 
to  a  minimum.  Flexion  is  the  most  marked  fea- 
ture in  this  position.  Its  effect  is  pronounced. 
It  relaxes  the  main  part  of  the  Y  ligament,  which, 
when  the  limb  is  straight,  is  drawn  as  an  unyield- 
ing band  across  the  front  of  the  joint.  Abduc- 
tion relaxes  the  outer  limb  of  this  ligament  and 
the  upper  part  of  the  capsule.  Eversion  slightly 
relaxes  the  inner  limb  of  the  Y  ligament  and  the 


Chap.  XIXj 


REGION    OF   THE   HIP 


497 


ischio-femoral  ligament.  The  latter  movement  is 
the  least  marked,  since  eversion,  even  in  the  flexed 
position  of  the  joint,  is  resisted  by  the  outer  part 
of  the  Y  ligament.  Any  but  a  moderate  degree  of 
abduction  would  be  limited  by  the  pubo-femoral 
ligament,  especially  as  that  band  is  rendered  most 
tense  when  abduction  is  combined  with  flexion 
and  rotation  out- 
wards. The  attach- 
ments of  the  psoas 
muscle  are  approxi- 
mated and  its  pres- 
sure over  the  joint 
relaxed. 

(2).  The  apparent 
lengthening  is  due  to 
the  tilting  down  of 
the  pelvis  on  the  dis- 
eased side,  and  is  the 
result  of  the  pa- 
tient's attempts  to 
overcome  the  effects 
of  the  position  just 
described.  The  limb 
is  shortened  by 
flexion  and  abduc- 
tion, and  to  bring  A 
the  foot  again  to  the  pi 
ground  and  to  re 
store  the 
parallelism  of  the 
limbs,  the  pelvis  has 
to  be  tilted  down  on 
the  affected  side.  Thus,  an  apparent  lengthening  is 
produced,  which  is  seen  when  the  patient  lies  upon 
a  bed  and  the  abduction  is  made  to  disappear.  Real 
lengthening  of  the  limb  can  scarcely  be  produced 
by  the  effusion  into  the  joint.  By  forcible  injection 
into  the  joint  Braune  could  only  separate  the  arti- 
culating surfaces  about  -,th  of  an  inch. 

(3).   The  lordosis,  or  curving  forwards,   of  the 
spine    occurs    in    the    dorso-lumbar    region.       It 
2g 


7,. — Diagram  to  show  the  mode  of 
production  of  lordosis  in  hip  disease. 

natural  A-  Femur  flexed  at  hip,  pelvis  (represented 
by  the  dotted  line)  straight,  and  spine 
normal,  b,  The  flexion  concealed  or  over- 
come by  lordosis  of  the  spine;  the  pelvis 
rendered  oblique. 


498  SUKGICAL   APPLIED    ANATOMY      [Part  V 

depends  upon  the  flexion  of  the  limb,  and  is  the 
result  of  an  attempt  to  conceal  that  false  position, 
or  at  least  to  minimise  its  inconveniences  (Fig. 
77).  When  the  thigh  is  flexed  at  the  hip  by- 
disease,  the  lower  limb  can  be  made  to  appear 
straight  by  simply  bending  the  spine  forwards  in 
the  dorso-lumbar  region  without  effecting  the  least 
movement  at  the  disordered  joint.  Indeed,  the 
movement  proper  to  the  hip  is  in  this  case  trans- 
ferred to  the  spine.  A  patient  with  a  flexed  hip 
as  the  result  of  disease  can  lie  on  his  back  in  bed, 
with  both  limbs  apparently  perfectly  straight,  he 
having  concealed  the  flexion,  as  it  were,  by  pro- 
ducing a  lordosis  of  the  spine.  If  the  lordosis  be 
corrected  and  the  spine  be  made  straight  again, 
then  the  flexion  of  the  hip  reappears,  although 
all  the  time  the  hip-joint  has  been  absolutely 
rigid.  This  lordosis  generally  appears  a  little 
late  in  the  disease,  and  after  the  limb  has  become 
more  or  less  fixed  in  the  false  positions  by  con- 
traction of  the  surrounding  muscles. 

(4).  Sooner  or  later,  in  hip  disease,  the  thigh 
becomes  adducted  and  inverted,  while  it  still 
remains  flexed.  The  head  of  the  femur  then  rests 
on  the  upper  and  posterior  part  of  the  acetabu- 
lum, quite  half  of  it  being  outside  the  socket. 
This  position  has  been  variously  accounted  for. 
According  to  one  theory,  it  is  due  to  softening  and 
yielding  of  some  parts  of  the  inflamed  capsule. 
It  is  more  probable  that  this  false  position,  and 
especially  the  adduction,  depends  upon  muscular 
action.  The  muscles  about  the  joint  are  in  a 
state  of  irritability.  They  are  contracted  by  a 
reflex  action  that  starts  from  the  inflamed  articu- 
lation, and  since  the  adductor  muscles  are  sup- 
plied almost  solely  by  the  obturator  nerve,  it  is 
not  unreasonable  to  expect  them  to  be  especially 
disturbed  if_  the  large  share  tfrat  the  obturator 
nerve  takes  in  the  supply  of  the  hip  be  borne  in 
mind.  The  whole  matter,  however,  requires 
further  investigation. 

(5).  Apparent  shortening  of  the  limb  is  due  to 


Chap.  XIX] 


REGION    OF   THE   HIP 


499 


tilting  up  of  the  pelvis  on  the  diseased  side,  and 
bears  the  same  relation  to  adduction  that  ap- 
parent lengthening  bears  to  abduction.  To  over- 
come the  adduction,  and  to  restore  the  natural 
parallelism  of  the  limbs,  the  patient  tilts  up  one 
side  of  his  pelvis  (Fig.  78).  It  thus  happens  that 
a  patient  with  his  femur  flexed  and  adducted  by 
disease  may  lie  in  bed  with  both  limbs  quite 
straight  and  parallel,  but  with  one  limb  obviously 


B 


B 


B 


Fig.   7S. — A,   Parts  in  normal  position.     B,   The  adduction  corrected  by 
tilting  up  tlie  pelvis.     C,   Femur  adducted. 

AC,  Line  of  pelvis  ;  ab,  limb  on  diseased  side  :  CD,  limb  on  sound  side  ;  E,  the  spine. 
It  will  be  found  that  in  Figs.  B  and  C  the  angle  at  A  is  the  same  in  the  two 

cases. 

shorter  than  the  other.  The  flexion  in  such  a  case 
is  concealed  by  lordosis,  and  the  adduction  by 
the  tilting  of  the  pelvis.  In  some  cases  of  simul- 
taneous disease  in  both  hip-joints  that  has  been 
indifferently  treated,  both  thighs  may  remain  ad- 
ducted. The  limbs  are  unable,  of  course,  to 
remedy  their  position  by  the  usual  means,  when 
the  disease  is  double,  and  consequently  one  limb 
is  crossed  in  front  of  the  other,  and  the  peculiar 
mode  of  progression  known  as  "  cross-legged  pro- 
gression ;'  is  produced. 


500  SURGICAL    APPLIED    ANATOMY      [Part  V 

(6).  The  real  shortening  depends  upon  destruc- 
tive changes  in  the  head  of  the  bone,  or  upon 
dislocation  of  the  partly  disintegrated  head  on  to 
the  dorsum  ilii,  through  yielding  of  the  softened 
capsule  and  the  crumbling  away  of  the  upper  and 
posterior  margin  of  the  acetabulum. 

When  hip  disease  commences  in  the  bone  it 
usually  involves  the  epiphyseal  line  that  unites 
the  head  of  the  femur  to  the  neck.  This  line  is 
wholly  within  the  joint,  and  the  epiphysis  that 
forms  the  head  unites  with  the  rest  of  the  bone 
about  the  eighteenth  or  nineteenth  year  (Fig.  76). 

When  the  bone  is  primarily  involved  the  posi- 
tion of  flexion  and  abduction  with  eversion  may 
not  be  observed  at  all,  there  being  no  effusion  at 
first  into  the  joint.  In  such  cases  the  limb  be- 
comes at  once  flexed  and  adducted,  and  this  pos- 
ture is  probably  due  solely  to  muscular  spasm, 
and  to  an  attempt  to  prevent  the  head  of  the 
femur  from  pressing  against  the  acetabulum,  and 
so  causing  pain. 

It  is  well  known  that  patients  with  hip  disease 
often  complain  of  pain  in  the  knee.  This  referred 
pain  may  be  so  marked  as  to  entirely  withdraw 
attention  from  the  true  seat  of  disease.  Thus  I 
once  had  a  child  sent  to  the  hospital  with  a  sound 
knee  carefully  secured  in  splints,  but  without  any 
appliance  to  the  hip,  which  was  the  seat  of  a 
somewhat  active  inflammation.  This  referred 
pain  is  easy  to  understand,  since  the  two  joints 
are  supplied  from  the  same  segments  of  the  spinal 
cord.  In  the  hip,  branches  from  (1)  the  anterior 
crural  enter  at  the  front  of  the  capsule ;  (2) 
branches  from  the  obturator  at  the  lower  and 
inner  part  of  the  capsule  :  and  (3)  branches  from 
the  sacral  plexus  and  sciatic  nerve  at  the  pos- 
terior part  of  the  joint.  In  the  knee,  branches 
from  (1)  the  anterior  crural  (nerves  to  vasti) 
enter  at  the  front  of  the  capsule ;  (2)  branches 
from  the  obturator  at  the  posterior  part  of  the 
capsule  ;  and  (3)  branches  from  the  internal  and 
external   popliteal   divisions   of  the  great   sciatic 


Chap.  XIX]  REGION    OF   THE   HIP  50l 

nerve   at   the   lateral   and   hinder   aspects   of   the 
joint. 

Pain,  therefore,  in  the  front  of  the  knee,  on 
one  or  both  sides  of  the  patella,  has  probably  been 
referred  along  the  anterior  crural  curve,  and 
pain  at  the  back  of  the  joint  along  the  obturator 
or  sciatic  nerves. 

In  hysterical  individuals  joint  disease  may  be 
imitated  by  certain  local  nervous  phenomena,  the 
articulation  itself  being  quite  free  from  struc- 
tural change.  This  affection  most  commonly 
shows  itself  in  the  hip  or  knee,  and  the  "  hys- 
terical hip,"  or  "  hysterical  knee,;'  takes  a  prom- 
inent place  in  the  symptomatology  of  hysteria. 
It  is  not  quite  easy  to  understand  why  these  two 
large  joints  should  be  so  frequently  selected  for 
the  mimicry  of  disease.  Hilton  has  endeavoured 
to  explain  the  fact  upon  anatomical  grounds, 
having  reference  to  the  nerve  supply  of  these 
joints  in  relation  to  the  nerve  supply  of  the 
uterus.  The  uterus  is  mainly  supplied  by  an 
offshoot  from  the  hypogastric  plexus,  and  by  the 
third  and  fourth  sacral  nerves.  Now,  the  hypo- 
gastric plexus  contains  filaments  derived  from  the 
lower  lumbar  nerves;  and  from  the  same  trunks 
two  nerves  to  the  hip  and  knee  (the  anterior 
crural  and  obturator)  are  in  great  part  derived. 
The  great  sciatic  also  contains  a  large  portion 
of  the  third  sacral  nerve.  The  common  origin  of 
the  joint  and  uterine  nerves  forms  the  basis 
of  Hilton's  explanation  of  the  relative  frequency 
of  hysterical  disease  in  the  large  articulations  of 
the  lower  limb.  The  explanation,  however,  is  un- 
satisfactory, since  the  uterus  receives  many  of  its 
nerves  from  the  ovarian  plexus,  and  the  theory  is 
founded  upon  the  unwarranted  supposition  that 
all  hysterical  disorders  are  associated  with  some 
affection  of  the  uterus  or  its  appendages.  More 
recently  Head  has  revived  a  modified  form  of 
Hilton's  theory.  He  explains  the  connection  not 
through  an  anatomical  association  of  nerves,  but 
through  an  association  of  the  centres  from  which 


502  SUEGICAL   APPLIED    ANATOMY     [Part  V 

nerves  arise  in  the  spinal  cord.  The  spinal  seg- 
ments from  which  the  obturator  nerve  arises,  the 
second,  third,  and  fourth,  contain  no  visceral 
nerves,  and,  therefore,  cannot  be  associated  with 
visceral  conditions.  On  the  other  hand,  the 
sacral  segments  from  which  the  great  sciatic  nerve 
arises  are  those  which  supply  the  pelvic  viscera. 

Fractures  of  the  upper  end  of  the  femur 
may  be  divided  into  (1)  fractures  of  the  neck 
wholly  within  the  capsule ;  (2)  fractures  of  the 
base  of  the  neck  not  wholly  within  the  capsule ; 
(3)  fractures  of  the  base  of  the  neck  involving  the 
great  trochanter ;  (4)  separations  of  epiphyses.  It 
can  be  scarcely  possible,  apart  from  gunshot  in- 
juries, to  fracture  the  neck  of  the  femur  by  direct 
violence,  owing  to  the  depth  at  which  the  bone 
is  placed,  and  the  manner  in  which  it  is  protected 
by  the  surrounding  muscles.  The  violence,  there- 
fore, that  causes  the  lesion  is  nearly  always  sup- 
plied indirectly  to  the  bone,  as  by  a  fall  upon  the 
feet  or  great  trochanter,  or  by  a  sudden  wrench 
of  the  lower  limb. 

(1).  The  true  intercapsular  fracture  may  involve 
any  part  of  the  cervix  within  the  joint,  but  is 
most  usually  found  near  the  line  of  junction  of 
the  head  with  the  neck.  This  fracture  is  most 
common  in  the  old,  in  whom  it  may  be  produced 
by  very  slight  degrees  of  violence.  The  liability 
of  the  aged  to  this  lesion  is  explained  upon  the 
following  grounds  :  The  angle  between  the  neck 
and  shaft  of  the  femur,  which  is  about  130°  in 
a  child,  tends  to  diminish  as  age  advances,  so 
that  in  the  old  it  is  commonly  about  125°.  In 
certain  aged  subjects,  as  a  result  probably  of  gross 
degenerative  changes,  this  angle  may  be  reduced 
to  a  right  angle.  This  diminution  of  the  angle 
certainly  increases  the  risk  of  fracture  of  the 
neck  of  the  bone.  There  is  often,  also,  in  ad- 
vanced life,  much  fatty  degeneration  of  the  can- 
cellous tissue  of  the  cervix  with  thinning  of  the 
compact  layer.  Dr.  Merkel  (Amer.  Journ.  Med. 
Sc,    1874)  also  asserts  that  in  old  persons  there    is 


Chap.  XIX]  REGION    OF   THE   HIP  503 

an  absorption  of  that  process  of  the  cortical  sub- 
stance which  runs  on  the  anterior  part  of  the  neck 
between  the  lesser  trochanter  and  the  under  part 
of  the  head.  This  process  he  calls  the  "  calcar 
femorale,"  and  maintains  that  it  occupies  the 
situation  at  which  the  greatest  pressure  falls  when 
the  body  is  erect.  These  fractures  are  but  rarely 
impacted ;  but  when  impacted,  the  lower  frag- 
ment, represented  by  the  relatively  small  and 
compact  neck,  is  driven  into  the  larger  and  more 
cancellous  fragment  made  up  of  the  head  of  the 
bone.  The  fracture  may  be  subperiosteal,  or  the 
fragments  may  be  held  together  by  the  reflected 
portion  of  the  capsule.  These  reflected  fibres  pass 
along  the  neck  of  the  bone  from  the  attachment 
of  the  capsule  at  the  femur  to  a  point  on  the 
cervix  much  nearer  to  the  head.  "  These  reflected 
fibres  occur  at  three  places,  one  corresponding  in 
position  to  the  middle  of  the  ilio-femoral  liga- 
ment, another  to  the  pectineo-femoral,  and  the 
third  on  the  upper  and  back  part  of  the  neck  " 
(Henry  Morris).  Fractures  of  this  part  very 
rarely  indeed  unite  by  bone.  Blood  is  brought  to 
the  head  of  the  femur  by  vessels  in  the  neck  of  the 
bone,  in  the  reflected  parts  of  the  capsule,  and  in 
the  ligamentum  teres.  When  the  first  two  sources 
of  blood  supply  are  cut  off  by  the  fracture,  the 
third  does  not  appear  to  be  sufficient  to  allow  of 
great  reparative  changes  taking  place  in  the 
upper  fragment.  The  fractures  that  heal  by  bone 
are  probably  either  impacted,  or  subperiosteal,  or 
not  wholly  intracapsular. 

(2).  With  regard  to  fractures  at  the  base  of  the 
neck,  it  must  be  remembered  that  a  wholly  extra- 
capsular fracture  of  the  neck  of  the  femur  is  an 
anatomical  impossibility.  If  the  fracture  is 
wholly  without  the  capsule,  then  it  must  involve  a 
part  of  the  femoral  shaft,  and  cannot  be  entirely 
through  the  cervix.  In  the  front  of  the  bone  the 
capsule  is  attached  to  the  femur  along  the 
intertrochanteric  line,  and  strictly  follows  the 
line  of  junction  between  the  cervix  and  the  shaft. 


504  SURGICAL    APPLIED    ANATOMY      [Part  V 

Behind,  the  capsule  is  inserted  into  the  neck  about 
^  an  inch  above  the  posterior  intertrochanteric 
line.  It  is  therefore  possible  for  a  fracture  of  the 
neck  to  be  extracapsular  behind,  but  not  in  front, 
and  many  of  these  lesions  at  the  base  of  the  neck 
have  this  relation  to  the  capsule.  The  Y  liga- 
ment is  so  thick,  being  in  one  place  about  \  of  an 
inch  in  thickness,  that  a  fracture  involving  the 
base  of  the  cervix  may  run  between  its  fibres  at 
their  attachment,  and  be  neither  extra-  nor  intra- 
capsular. When  fractures  at  the  junction  of  the 
neck  and  shaft  are  impacted,  the  upper  fragment, 
represented  by  the  compact  and  relatively  small 
cervix,  is  driven  into  the  cancellous  tissue  about 
the  great  trochanter  and  upper  end  of  the 
shaft.  As  a  result  of  this  impaction  the  tro- 
chanter may  be  split  up,  and  the  bones  may  be- 
come free  again  through  the  extent  of  this 
splintering. 

With  regard  to  the  symptoms  of  a  fracture 
of  the  neck  of  the  feimir,  the  following  may 
be  noticed  :  (a)  The  swelling  often  observed  in 
the  front  of  the  limb,  just  below  Poupart's  liga- 
ment, is  due  either  to  effusion  of  blood  into  the 
joint  or  to  projection  of  the  fragments  against 
the  front  of  the  capsule ;  (b)  the  shortening  is 
brought  about  by  the  glutei,  the  hamstrings,  the 
tensor  vaginae  femoris,  the  rectus,  sartorius,  and 
ilio-psoas,  the  adductors,  gracilis  and  pectineus ; 
(c)  the  eversion,  or  rotation  outwards  of  the  limb, 
is  mainly  due  to  two  causes  :  (i.)  the  weight  of 
the  limb,  which  causes  it  to  roll  outwards,  as  is 
seen  in  persons  insensible  or  asleep,  the  line  of 
gravity  passing  through  the  outer  part  of  the 
thigh;  (ii.)  the  fact  that  the  compact  tissue  on  the 
posterior  aspect  of  the  neck  is  much  more  fragile 
than  that  on  the  anterior  aspect.  Thus  the  cervix 
is  often  more  extensively  fractured  behind  than  in 
front,  or  the  fracture  may  be  impacted  behind 
but  not  in  front,  and  in  either  case  the  limb  will 
tend  to  become  everted.  As  a  third  cause  may 
be    mentioned    the    action    of    the    ilio-psoas,    the 


Chap.  XIX]  REGION    OF   THE    HIP 


505 


adductor  and  pectineus  muscles,  and  of  the  small 
rotator  muscles,  all  of  which  will  tend  to  roll  the 
femur  outwards. 

(3).  Fracture  of  the  base  of  the  neck,  involving 
the  great  trochanter.  In  this  lesion  the  head, 
the  cervix,  and  a  part  of  the  great  trochanter 
are  separated  from  the  shaft  and  rest  of  the  tro- 
chanter. 

(4).  Separation  of  epiphyses.  There  are  three 
epiphyses  in  the  upper  end  of  the  femur  :  one  for 
the  head,  which  unites  between  eighteen  and  nine- 
teen;  one  for  the  lesser  trochanter,  which  unites 


Fig.   79. — Illustrating    the    ossification  of   the    upper  extremity  of   the 
femur  and  the  condition  of  coxa  vara.     {After  Elmslie.) 

a,  The  upper  extremity  at  birth. 

b,  ,,        „  „  „  2nd  year. 

c,  „        „  „  „  4th  year. 

jj,    „        ,,  „  of  a  femur  from ' 

a  subject  of  coxa  vara. 

about  seventeen ;  and  one  for  the  greater  tro- 
chanter, which  unites  about  eighteen.  The  neck 
is  formed  by  an  extension  of  ossification  from  the 
shaft  (Fig.'  79).  The  epiphysis  for  the  head  is 
secured  against  separation  by  being  shaped  like  a 
cap,  by  its  epiphyseal  line  being  arranged  trans- 
versely to  the  axis  of  the  femur,  and  also  by  its 
intracapsular  position.  The  epiphysis,  however, 
is  subject  to  a  peculiar  form  of  dislocation  which 
gives  rise  to  the  condition  of  coxa  vara.  The 
epiphysis  gradually  tilts  downwards  so  that  the 
neck  of  the  femur  appears  to  sink  under  the 
weight  of  the  body,  coming  to  form  an  angle  of 
90°  or  less  with  the  shaft  of  the  femur.  It  occurs 
in  adolescents.     Owing  to  the  prominence  of  the 


506 


SURGICAL   APPLIED    ANATOMY     [Part  V 


trochanter  and  shortening  of  the  limb  which 
necessarily  result,  the  condition  may  be  mistaken 
for  a  fracture  of  the  neck  of  the  femur  or  a  con- 
genital dislocation  of  the  hip-joint.  The  great 
trochanter  may  be  separated.  The  epiphyseal  lines 
of  the  head  and  great  trochanter  are  continuous 
until  the  neck  is  ossified  (see  Fig.  79). 

Dislocations  of  the  hip. — These  injuries  are 
comparatively  rare,  on  account  of  the  great 
strength  of  the  articulation,  and  when  they  occur 
in  a  healthy  joint  are  always  the  result  of  a  con- 
siderable degree  of  violence.     A  dislocation  of  the 


y-  5/iaped  Cartilage 

ACETABULUM 

PuBES 

5yMPnysis 


C.RT  TROCrtArtTER 


,2LyL-PECTIMEU3 

Adductor  lohCus 
Capsulc 
Psoas 


Fig    80.— Congenital  dislocation  of  the  hip. 

From  a  specimen  presented  to  the  London  Hospital  Medical  College  Museum 
by  Mr.  Openshaw.    It  was  obtained  from  a  child  aged  4  years. 

hip  may  be  congenital,  or  may  be  spontaneously 
produced  by  muscular  efforts,  as  shown  in  a  few 
rare  cases,  or  may  be  the  result  of  disease  of  the 
articulation.  Congenital  dislocation  of  the  hip- 
joint  is  due-  in  most  instances  to  a  failure  in  the 
development  of  the  acetabulum.  In  such  cases  the 
acetabulum  retains  the  shallow  character  seen 
during  the  second  month  of  foetal  life.  The  out- 
growth of  the  acetabular  rim  fails,  especially  in 
the  iliac  part.  The  acetabular  cavity  becomes 
filled  up  by  the  duplication  of  the  capsule,  which 
is  unduly  lax  (Fig.  80).  The  round  ligament  may 
be  intact  or  deficient.  The  head  of  the  femur  be- 
comes flat  and  the  neck  short,  and  the  bone  slips 
backwards    on    the    dorsum    ilii    when    the    child 


Chap.  XIX]         REGION    OF   THE   HIP  S07 

learns  to  walk.  The  weight  of  the  body  is  sup- 
ported by  the  muscles  and  ligaments  round  the 
hip-joint.  If  replaced  the  head  again  slips  from 
the  shallow  cavity.  In  time  osteophytic  out- 
growths from  the  ilium  lead  to  the  formation  of  a 
new  cavity.  The  deformity  is  evidently  corre- 
lated with  the  development  of  the  female  sexual 
organs,  for  it  is  practically  unknown  in  male 
children. 

In  dislocations  due  to  violence  the  head  of  the 
bone  may  be  found  displaced  in  four  directions, 
producing  the  four  regular  dislocations  of  the 
hip.  In  two  the  head  of  the  femur  is  posterior 
to  a  line  drawn  vertically  through  the  acetabulum, 
and  in  the  other  two  it  is  found  anterior  to  that 
line. 

(1)  Backwards  and  upwards.  Head  rests  upon 
ilium,  just  above  and  behind  acetabulum.  The 
"  dislocation  upon  the  dorsum  ilii."  (2)  Back- 
wards. Head  rests  upon  ischium,  and,  as  a  rule, 
about  on  a  level  with  the  ischial  spine.  The  "  dis- 
location into  the  sciatic  notch."  (3)  Forwards 
and  downwards.  Head  rests  on  thyroid  foramen. 
The  "  obturator  or  thyroid  dislocation"  (4)  For- 
wards and  upwards.  Head  rests  upon  the  body 
of  the  pubes,  close  to  its  junction  with  the  ilium. 
The  ''''dislocation  upon  the  pubes." 

The  above  arrangement  represents  also  the 
order  of  frequency  of  these  luxations,  No.  1  being 
the  most  common  dislocation  of  this  part,  and 
No.   4  the  most  rare. 

General  facts. — In  all  these  dislocations  of 
the  hip,  (a)  the  luxation  occurs  when  the  limb  is 
in  the  position  of  abduction  ;  (b)  the  rent  in  the 
capsule  is  always  at  its  posterior  and  lower  part; 
(c)  the  head  of  the  bone  always  passes  at  first  more 
or  less  directly  downwards ;  (a)  the  Y  ligament 
is  untorn,  while  the  ligamentum  teres  is  ruptured. 

(a)  It  is  maintained  that  in  all  luxations  at 
the  hip,  the  pelvis_  and  femur  are  in  the  mutual 
position  of  abduction  of  the  latter  at  the  time  of 
the   accident.     The    direction   of   the   neck   of   the 


508  SURGICAL    APPLIED    ANATOMY      [Part  V 

femur  and  of  the  acetabulum,  and  the  position  of 
the  cotyloid  notch,  all  favour  dislocation  in  the 
abducted  posture.  The  lower  and  inner  part  of 
the  acetabulum  is  very  shallow,  and  the  lower  and 
posterior  part  of  the  capsule  is  very  thin.  In 
abduction,  the  head  of  the  bone  is  brought  to  the 
shallow  part  of  the  acetabulum;  it  moves  more 
than  half  out  of  that  cavity ;  it  is  supported 
only  by  the  thin  weak  part  of  the  capsule,  and  its 
further  movement  in  the  direction  of  abduction 
is  limited  only  by  the  pubo-femoral  ligament,  a 
somewhat  feeble  band.  In  abduction  the  round 
ligament  is  slack,  and  in  abduction  with  flexion 
both  the  Y  ligament  and  the  ischio-femoral  liga- 
ments are  also  relaxed.  In  the  position  of  abduc- 
tion, therefore,  no  great  degree  of  force  may  be 
required  to  thrust  the  head  of  the  bone  through 
the  lower  and  posterior  part  of  the  capsule  and 
displace  it  downwards. 

(6)  The  above  being  allowed,  it  will  be  under- 
stood that  the  rent  in  the  capsule  is  always  at  its 
posterior  and  lower  parts.  "  Generally  the  rup- 
ture is  jagged  and  irregular,  but  will  be  found 
to  extend  more  or  less  directly  from  near  the 
shallow  rim  of  the  acetabulum,  across  the  thin 
portion  of  the  capsule  to  the  femur  near  the  small 
trochanter,  and  then  to  run  along  the  back  of  the 
ligament  close  to  its  attachment  to  the  neck  of  the 
bone  "  (Henry  Morris). 

(c)  If  the  position  of  the  limb  at  the  time  of  the 
accident  be  considered,  it  will  be  seen  that  the 
femur  will  in  every  case  be  displaced  downwards. 
There  is,  indeed,  but  one  primary  dislocation  of 
the  hip — a  luxation  downwards.  The  four  forms 
given  above  are  all  secondary,  the  bone  having  in 
each  instance  first  passed  downwards  before  it 
moved  to  any  of  the  positions  indicated.  This 
point  has  been  ably  demonstrated  by  Mr.  Henry 
Morris,  whose  account  of  the  anatomy  of  hip  dis- 
locations is  most  valuable.  The  head  having  left 
the  acetabulum,  its  ultimate  destination  will  de- 
pend upon  the  character  of  the  dislocating  force. 


Chap.  XIX] 


REGION    OF   THE   HIP 


509 


"  If  the  limb  be  flexed  on  the  pelvis,  and  rotated 
inwards,  or  the  pelvis  be  correspondingly  moved 
on  the  thigh  at  the  moment  of  displacement,  the 
head  of  the  femur  will  take  a  backward  course 
and  rest  on  the  dorsum  ilii  or  some  part  of  the 
ischium.  On  the  other  hand,  extension  and  out- 
ward rotation  will  cause  the  head  of  the  bone  to 
travel  upwards  and  forwards,  and  what  is  called 
a  dislocation  on  to  the  pubis  will  occur.  _  .  .  . 
If  the  dislocation  is  neither  accompanied  nor 
followed  by  rota- 
tion or  fixed 
flexion  or  exten- 
sion, the  head  of 
the  femur  will 
remain  below  the 
acetabulum,  and 
will  occupy  the 
foramen  ovale  if 
it  takes  a  slightly 
forward  direction 
in  its  descent, 
or  some  position 
near  the  tuber- 
osity of  the  ischi- 
um if  it  leaves  its 
socket  in  a  back- 
ward and  down- 
ward direction  J' 
(Henry  Morris). 
(d)  The  Y  liga- 
ment is  never 
torn  in  any  regu- 
lar dislocation.  It  is  saved  by  its  great  density 
and  the  circumstance  that  it  is  probably  more 
or  less  relaxed  at  the  time  of  the  luxation.  The 
method  of  reducing  these  dislocations  by  manipu- 
lation >  depends  for  its  success  mainly  upon  the 
integrity  of  the  Y  ligament,  which  acts  as  the 
fulcrum  to  a  lever  of  which  the  shaft  of  the 
femur  is  the  long  arm  and  the  neck  the  short. 
In  the  backward  luxations  the  head  is  behind  the 


Fig.  81. — Dislocation  upon  the  dorsum  ilii. 
(Bigeloiv.) 


510 


SURGICAL    APPLIED    ANATOMY      [Part  V 


Y  ligament,  and  in  the  forward  displacements  in 
front  of  it. 

The  anatomy  of  each  form. — Nos.  1  and  2. 

The  dislocations  backwards  (Fig.  81).  The  femoral 
head,  having  been  displaced  in  the  way;  indicated, 
is  carried  towards  the  dorsum  or  sciatic  notch 
by  the  glutei,  hamstring,  and  adductor^  muscles. 
The  bone  having  taken  a  general  direction  back- 
wards, the  height  to  which  it  ascends  •  depends 
mainly  upon  the  nature  of  the  dislocating  force, 
and  also  upon  the  extent  of  the  rupture  in  the 

capsule  and  the 
laceration  of  the 
obturator  internus 
tendon  and  other 
small  external  ro- 
tators. The  dorsal 
dislocation  is, 

therefore,  a  more 
advanced  grade  of 
the  sciatic.  The 
more  extreme  the 
flexion  and  inward 
rotation  at  the  time 
of  the  accident,  the 
more  likely  is  the 
dislocation  to  be 
sciatic.  More 

moderate  flexion 
and  inward  rota- 
tion will  produce  a 
luxation  upon  the 
dorsum.  In  the 
dorsal  luxation  the 
head  is  above  the 
obturator  internus  tendon,  while  in  the  sciatic 
form  it  is  below  it  (Bigelow).  Morris  has  been 
able  to  find  but  one  case  of  direct  dislocation  of 
the  femur  backwards  on  to  the  ischium.  In  every 
instance  it  passes  first  in  a  downward  direction, 
and  then  backwards. 

Bigelow  states  that  there  is  no  evidence  to  show 


Pig.  82. 


-Obturator  or  thyroid  dislocation. 
{Bigelow.) 


Chap.  XIX]         REGION    OF   THE    HIP 


511 


that  the  head  of  the  femur  has  even  been  actually 
displaced  into  the  sciatic  notch. 

In  these  backward  dislocations  the  ilio-psoas 
muscle  is  greatly  stretched.  The  quadratics 
femoris,  the  obturators,  the  gemelli,  and  the  pyri- 
formis  are  more  or  less 
lacerated.  The  pecti- 
neus  is  often  torn,  and 
the  glutei  muscles  even 
may  be  rupture  d_  in 
part.  The  great  sciatic 
nerve  may  be  compressed 
between  the  femoral 
neck  and  the  rotator 
muscles,  or  between  the 
head  of  the  bone  and 
the  tuber  ischii.  In  both 
of  the  backward  luxa- 
tions there  is  shorten- 
ing, due  to  the  circum- 
stance that  the  line 
between  the  anterior 
superior  spine  and  the 
femoral  condyles  is  les- 
sened by  the  displace- 
ment backwards  of  the 
bone,  with  the  additional 
shortening  in  the  dorsal 
dislocation  brought 
about  by  the  passing  of 
the  femoral  head  above 

the  level  of  the  acetabulum.  The  adduction  and 
inversion  in  the  main  depend  upon  the  position  of 
the  head  and  cervix,  which  must  follow  the  plane 
of  the  bone  upon  which  they  lie.  This  position  is 
maintained  by  the  tense  Y  ligament.  The  damage 
done  to  the  chief  external  rotators  places  them  also 
hors  de  combat.  The  flexion  is  due  to  the  tension 
of  the  Y  ligament  and  of  the  ilio-psoas  muscle. 

Nos.  3  and  4.  The  dislocation  forwards.  If 
the  head  after  leaving  the  acetabulum  simply 
moves  a  little  forwards  along  the  inner  edge  of  the 


Fig.  S3. 


-Dislocation  upon  the  pubes 
(Bigelow.) 


512  SUKGICAL    APPLIED    ANATOMY      [Part  V 

socket,  the  thyroid  luxation  is  produced  (Fig.  82). 
If  it  goes  farther  and  moves  upwards,  the  pubic 
displacement  will  result  (Fig.  83).  The  latter  dis- 
location is  therefore  but  an  advanced  form  of  the 
former.  Whether  the  head  will  remain  in  the  thy- 
roid foramen  or  ascend  on  to  the  pubes  depends  on 
whether  extension  and  rotation  outwards  accom- 
pany the  displacement.  If  these  occur  the  pubic 
form  is  produced.  In  these  injuries  the  pectineus, 
gracilis,  and  adductors  will  be  more  or  less  torn, 
while  the  ilio-psoas,  glutei,  and  pyriform  muscles 
are  much  stretched.  The  obturator  nerve  may  be 
stretched  or  torn,  and  in  the  pubic  luxation  the 
anterior  crural  nerve  may  be  involved.  The  ab- 
duction and  eversion  of  the  limb  noticed  in  these 
luxations  depend  partly  upon  the  position  of  the 
head  of  the  bone,  fixed  more  or  less  by  the  Y  liga- 
ment, and  partly  upon  the  action  of  the  gluteal 
muscles  and  some  of  the  small  external  rotators, 
which  are  tightly  stretched.  The  flexion  of  the 
limb  is  mainly  due  to  the  stretching  of  the  ilio- 
psoas muscle. 

In  the  thyroid  luxation  the  extremity  is  said 
to  be  lengthened.  This  lengthening  is,  however, 
only  apparent,  and  is  due  to  the  tilting  down  of 
the  pelvis  on  the  injured  side.  In  the  pubic 
dislocation  there  is  shortening,  the  head  being 
carried  above  the  acetabular  level. 

Of  the  modes  of  reducing  these  dislocations  by 
manipulation  little  can  be  said  here.     The  more 
usual  proceedings  may  be  briefly  summarised  as  follows  : 
First. — Flex  the  thigh  in  the  ad- \ 
ducted  position  in  luxa- 
tions Nos.   1  and  2.  To  relax  the 
Flex  the  thigh  in  the  ab-  f    Y  ligament, 
ducted  position  in  luxa- 
tions Nos.  3  and  4. 
Secondly. — Circumduct  out  in^jTo  bring  back  the 
Nos.  1  and  2.            head   to   the   rent 
c  in  the  capsule  by 
Circumduct   in    in     the  same  route  that 
JSTos.   3  and   1.      )  it  has  escaped. 


Chap.  XIX]  REGION    OF   THE    HIP  513 

Thirdly. — Extend    in    all    cases.     To    induce    the 
head  to  enter  the  acetabulum  again. 

In  reducing  dislocations  of  the  hip  it  may  be 
noted  that  the  internal  condyle  of  the  femur  faces 
in  nearly  the  same  direction  as  the  head  of  the 
bone. 

In  amputation  of  the  thigli  at  the  hip- 
joint  many  methods  may  be  employed.  A  com- 
mon procedure  consists  of  a  circular  incision 
which  divides  the  soft  parts  to  the  bone  at  the 
junction  of  the  upper  with  the  middle  thirds  of 
the  thigh,  and  is  combined  with  a  vertical  incision 
over  the  great  trochanter,  through  which  the 
upper  extremity  of  the  femur  is  exposed  and 
the  joint  disarticulated.  (See  section,  Fig.  76, 
p.  493.)  Haemorrhage  from  the  femoral,  gluteal,  and 
sciatic  vessels  is  prevented  either  by  compressing 
the  termination  of  the  abdominal  aorta  a  little 
below  and  to  the  left  of  the  umbilicus,  or  by  en- 
circling the  junction  of  the  thigh  and  body  with  a 
loop  of  elastic  bandage.  The  bandage  must  pass 
inside  the  ischial  tuberosity  to  compress  the  con- 
tents of  the  sacro-sciatic  foramen,  over  the  groin 
to  compress  the  femoral  vessels,  and  above  the  iliac 
crest  to  prevent  it  from  slipping  downwards.  In 
the  circular  incision  the  vessels  divided  are  :  the 
superficial  and  deep  femoral,  the  second  per- 
forating artery,  descending  branches  of  the  ex- 
ternal circumflex  arid  sciatic  vessels,  and  long 
saphenous  vein ;  the  nerves  divided  are  :  the 
external,  middle  and  internal  cutaneous,  the  in- 
ternal saphenous,  the  deep  muscular  branches  of 
the  anterior  crural,  the  obturator,  the  great  and 
small  sciatic ;  the  muscles  divided  are  :  the  sar- 
torius,  quadriceps  extensor  cruris,  adductors 
magnus  and  longus,  gracilis,  and  hamstrings.  In 
the  vertical  incision  (Fig.  76,  p.  493)  the  ilio-tibial 
band  and  the  insertions  of  all  the  gluteal  muscles 
are  divided  to  the  bone.  Communicating  branches 
between  the  ascending  and  transverse  branches  of 
the  external  circumflex  artery  in  front  with  the 
gluteal,  sciatic  and  first  perforating  behind  are 
2  H 


514  SURGICAL    APPLIED    ANATOMY      [Part  V 

cut.  The  capsule  of  the  joint  is  divided,  the  head 
of  the  femur  thrust  from  its  socket,  and  the  liga- 
mentum  teres  cut.  The  attachments  of  the  follow- 
ing structures  to  the  upper  third  of  the  femur 
have  to  be  separated  :  the  gluteus  maximus, 
medius,  minimus,  pyriformis,  gemelli,  obturator 
internus  and  externus,  quadratus  femoris,  ad- 
ductor magnus,  brevis,  pectineus,  psoas  and  ilia- 
cus,  with  the  capsular  ligament. 

By  the  method  of  disarticulation  at  the  hip- 
joint  known  as  the  anterior  racket,  no  elastic 
tourniquet  and  no  compression  of  the  iliac  vessels 
are  needed. 

The  vertical  part  of  the  racket-shaped  incision 
is  placed  over  the  femoral  vessels,  and  those  ves- 
sels are  secured  by  two  ligatures  each  and  are 
then  severed  between  the  ligatures.  The  circum- 
flex arteries  are  in  the  same  way  secured  before 
division. 

If  carefully  performed,  very  little  blood  is  lost 
in  the  anterior  racket  amputation. 


CHAPTER    XX 
THE    THIGH 

Under  the  term  "  the  thigh  ';  it  will  be  convenient 
to  describe  that  part  of  the  lower  limb  that  ex- 
tends between  the  regions  just  described  and  the 
districts  of  the  knee  and  popliteal  space. 

Surface  anatomy. — In  muscular  subjects  the 
outline  of  the  thigh  is  irregular,  but  in  the  less 
muscularly  developed,  who  are  provided  with  a 
good  share  of  subcutaneous  fat,  the  limb,  in  this 
section  of  it,  is  more  or  less  evenly  rounded.  The 
prominence  of  the  rectus  muscle  is  noticeable  on 
the  front  of  the  thigh,  especially  when  the  muscle 
is  in  action.  To  the  inner  side  of  this  structure, 
and  conspicuous  along  the  lower  half  of  the  thigh, 
is  the  eminence  formed  by  the  vastus  internus. 
The  mass  to  the  outer  side  of  the  rectus  is  com- 
posed of  the  external  vastus  muscle,  and  occupies 
the  greater  part  of  the  limb  in  this  region,  being, 
however,  more  conspicuous  below. 

Running  down  the  anterior  and  inner  aspect  of 
the  thigh,  from  the  apex  of  Scarpa's  triangle, 
is  a  depression  which  indicates  the  interval  be- 
tween the  quadriceps  muscle  and  the  adductors. 
Along  this  groove  the  sartorius  lies.  Over  the 
surface  of  the  vastus  externus  a  longitudinal  de- 
pression is  often  to  be  observed,  formed  by  the 
pressure  exercised  bv  the  superimposed  ilio-tibial 
band  of  the  fascia  lata.  The  hamstring  muscles 
cannot  usually  be  distinguished  the  one  from  the 
other    above    the    popliteal    space,    nor    is    their 

515 


516  SURGICAL    APPLIED    ANATOMY      [Part  V 

separation  from  the  adductors  indicated.  The 
separation,  however,  between  them  and  the  vastus 
externus  is  distinct,  and  corresponds  to  the  posi- 
tion of  the  external  intermuscular  septum.  The 
line  of  the  femoral  vessels  has  already  been  given 
(p.  487).  The  long  saphenous  vein  follows  in 
the  thigh  the  course  of  the  sartorius  muscle,  and 
may  be  represented  on  the  surface  by  a  line  drawn 
from  the  region  of  the  saphenous  opening  (p.  487) 
to  the  posterior  border  of  the  sartorius  muscle 
at  the  level  of  the  inner  condyle  of  the  femur. 
The  long  saphenous  nerve  follows  the  course  of  the 
femoral  artery,  lying  first  to  the  outer  side  of  that 
vessel  and  then  gradually  crossing  it.  In  the 
lower  fourth  of  the  thigh  the  nerve  passes  under 
cover  of  the  sartorius  muscle  to  the  inner  side  of 
the  knee,  and  is  accompanied  by  the  superficial 
branch  of  the  anastomotic  artery.  A  line  drawn 
down  the  back  of  the  limb  from  a  point  midway 
between  the  great  trochanter  and  tuber  ischii  to 
the  middle  of  the  ham  will  correspond  to  the 
great  sciatic  nerve  and  one  of  its  continuations, 
the  internal  popliteal  (see  p.  480).  The  great  trunk 
usually  bifurcates  a  little  below  the  middle  of 
the  thigh. 

The  skin  of  the  thigh  is  coarse  on  the  outer 
side  of  the  limb,  but  internally  it  is  thin  and  fine, 
and  is  apt  to  be  readily  excoriated  by  ill-applied 
bandages  or  splints.  It  is  but  loosely  attached  to 
the  subjacent  parts,  a  circumstance  that  greatly 
favours  the  performance  of  circular  amputations  . 
in  this  region.  At  one  place,  however,  it  is  a 
little  more  adherent,  viz.  along  the  groove  that 
separates  the  vastus  externus  from  the  hamstring 
muscles,  and  that  corresponds  to  the  outer  inter- 
muscular septum.  The  laxity  of  the  subcutaneous 
tissue  favours  extensive  extravasations  beneath 
the  skin,  and  permits  of  large  flaps  of  integu- 
ment being  torn  up  in  cases  of  injury  to  this  part 
of  the  extremity. 

The   fascia  lata  invests  the  limb  at  all  parts 
like  a  tightly  fitting  sleeve.     It  is  thickest  at  its 


Chap.  XX]  THE   THIGH  517 

outer  side,  where  it  forms  the  dense  ilio-tibial 
band.  It  is  thinnest  at  the  upper  and  inner  as- 
pect of  the  thigh,  where  it  covers  the  adductor 
muscles.  It  increases  considerably  in  strength  as 
it  approaches  the  front  of  the  knee,  and  attaches 
itself  to  the  tibia  and  lateral  margins  of  the 
patella.  This  fascia  resists,  especially  at  its  outer 
part,  the  growth  of  tumours  and  abscesses,  and 
limits  deep  extravasations  of  blood.  It  has  occa- 
sionally been  ruptured  in  part  by  violence,  and 
through  the  rent  so  formed  the  subjacent  muscle 
has  bulged,  forming  what  is  known  as  a  hernia 
of  the  muscle.  This  condition  has  been  met  with 
in  the  case  of  the  quadriceps  muscle,  and  also 
of  the  adductor  longus.  Such  "  hernise  ,;  are 
probably  associated  with  some  rupture  of  the  fibres 
of  the  muscles  implicated.  Two  deep  processes 
of  the  fascia  are  attached  to  the  femur,  and 
form  the  outer  and  inner  intermuscular  septa. 
The  outer  septum  separates  the  vastus  externus 
from  the  biceps,  and  the  inner  the  vastus  internus 
from  the  adductors.  Together  with  the  fascia 
lata,  these  septa  divide  the  thigh  into  two  apo- 
neurotic spaces,  which  can  be  displayed  in  a 
transverse  section  of  the  limb.  These  divisions, 
however,  are  of  little  surgical  moment,  and  the 
inner  septum  is  often  so  thin  and  feeble  that  it 
could  have  but  little  effect  in  directing  the  course 
of  an  abscess. 

In  circular  amputations  of  the  thigh  the 
muscles  are  apt  to  retract  a  little  unevenly,  since 
some  are  attached  to  the  femoral  shaft  while 
others  are  free.  The  muscles  so  attached  are  the 
adductors,  vasti  and  crureus,  while  the  free  mus- 
cles are  the  sartorius,  rectus,  hamstrings,  and 
gracilis. 

In  spite  of  its  great  strength  the  tendon  of  the 
quadriceps  may  be  ruptured  by  muscular  violence. 
A  good  example  of  such  an  accident  is  recorded 
by  Mr.  Bryant  (Med.  Times,  1878).  A  man  aged 
forty-two  stumbled  in  the  dark,  and  fell  down  a 
pit   ten    feet   deep.     On    examination   the   tendon 


518  SURGICAL   APPLIED    ANATOMY      [Part  V 

was  found  to  be  torn  across,  and  the  gap  above  the 
patella  produced  by  the  rupture  occupied  no  less 
extent  than  the  lower  third  of  the  thigh.  A  some- 
what more  remarkable  accident  is  reported  to  have 
happened  to  the  sartorius  muscle.  This  muscle, 
just  before  its  insertion  into  the  tibia,  gjives  oft' 
an  aponeurotic  expansion  from  its  anterior  bor- 
der to  the  capsule  of  the  knee-joint.  In  the  case 
alluded  to  (Lancet,  1873),  this  expansion  is  said 
to  have  been  ruptured,  and  the  muscle  itself  to 
have  been  found  dislocated  backwards  in  conse- 
quence. The  accident  befell  a  man  aged  forty, 
who  was  squatting,  in  the  position  assumed  by 
tailors,  upon  the  floor  of  a  waggon,  when  his  com- 
panion tripped  over  him  and  fell  across  his  bent 
knees.  Something  was  felt  to  have  given  way 
near  the  ham,  and  on  examination  the  above  lesion 
was  diagnosed. 

The  femoral  artery  may  be  ligatured  at  any 
part  of  its  course  in  the  thigh,  and  the  com- 
paratively superficial  position  of  the  vessel  ren- 
ders it  very  liable  to  be  injured.  In  the  middle 
third  of  the  thigh  it  lies  beneath  the  sartorius  in 
Hunter's  canal.  The  thigh  affords  many  instances 
of  the  remarkable  way  in  which  isolated  branches 
of  a  main  artery  are  often  alone  damaged.  Thus, 
Langier  relates  the  case  of  a  man-cook,  who,  in 
running  round  a  table,  struck  the  upper  and 
outer  side  of  his  thigh  against  the  corner  of  it. 
This  led  to  a  subcutaneous  rupture  of  the  external 
circumflex  artery.  Unfortunately  the  extravasa- 
tion was  cut  into,  and  the  patient,  after  being 
subjected  to  many  modes  of  treatment,  died  from 
the  effects  of  repeated  haemorrhage.  Dr.  Butcher 
(Dub.  Joum.  Med.  Sc,  1874)  gives  the  case  of  a 
man  who  was  stabbed  in  the  thigh  over  the  femoral 
vessels  during  a  scuffle.  Profuse  bleeding  fol- 
lowed, and  it  was  found  that  the  only  vessel 
wounded  was  the  internal  circumflex  artery,  just 
at  its  point  of  origin  from  the  profunda.  The 
case  was  treated  promptly  and  the  man  did  well. 

Fractures   of  the    femur. — The  shaft  of  the 


Chap.  XX]  THE    THIGH  519 

femur  may  be  broken  at  any  part,  but  the  lesion 
is  most  common  at  the  middle  third  of  the  bone, 
and  least  frequent  at  its  upper  third.  If  broken 
by  direct  violence  the  fracture  is  usually  trans- 
verse, and  if  by  indirect  violence  it  is  usually 
oblique.  The  probability  of  a  fracture  being  due 
to  direct  violence  diminishes  in  the  bone  from 
below  upwards,  while  the  probability  of  a  lesion 
from  indirect  violence  increases  in  the  same  direc- 
tion. Thus  it  happens  that  the  fractures  of  the 
upper  third  of  the  bone  are  usually  oblique,  while 
those  of  the  lower  third  are  more  commonly  trans- 
verse. In  the  middle  third  the  numbers  of  the 
transverse  and  oblique  fractures  are  more  nearly 
balanced.  The  femur  has  <  often  been  broken  by 
muscular  violence,  but  it  is  doubtful  if  this  has 
ever  occurred  in  other  than  a  diseased  bone.  In 
many  of  these  cases  the  amount  of  force  that 
breaks  the  bone  is  most  insignificant.  Thus  Val- 
lin  reports  the  case  of  a  girl  aged  eighteen,  de- 
scribed as  robust,  who  broke  the  femur  about  its 
middle  while  in  the  act  of  mounting  a  table  for 
the  purpose  of  undergoing  a  vaginal  examination. 
In  oblique  fractures  in  the  upper  third  of  the  bone 
the  line  of  fracture  usually  runs  downwards  and 
inwards,  while  in  oblique  fractures  of  the  middle 
third  the  direction  is  more  commonly  downwards 
and  forwards^  with  a  slight  lateral  inclination 
that  is  sometimes  inwards  and  sometimes  out- 
wards. Fractures  of  the  lower  third  of  the  bone 
are  discussed  in  connection  with  the  region  of  the 
knee  (chap.  xxi.). 

_  With  regard  to  fractures  of  the  upper  and 
middle  thirds,  the  displacements  of  the  fragments 
depend  greatly  upon  the  obliquity  of  the  fracture. 
As  a  rule  the  lower  fragment  is  drawn  up  behind 
the  upper  one  by  the  hamstrings,  aided  by  the 
rectus,  gracilis,  sartorius,  tensor  vaginae,  and 
adductors,  and  is  carried  a  little  to  its  inner  side 
under  the  influence  of  the  last-named  muscles. 
The^  lower  end  of  the  upper  fragment  usually 
projects   forwards    and   a   little    backwards.     This 


520  SURGICAL    APPLIED    ANATOMY     [Part  V 

is  produced  by  the  agency  of  the  lower  fragment, 
which  tilts  the  upper  piece  of  bone  in  the^  direction 
named.  In  the  fracture  of  the  upper  third  of  the 
shaft  the  projection  forwards  of  the  upper  frag- 
ment is  aided  by  the  ilio-psoas  muscle.  Thus  the 
deformity  produced  in  fractures  of  the  femoral 
shaft  is  usually  angular  in  character.  The  ever- 
sion  of  the  foot  noted  in  fractures  of  the  femur  is 
due  to  the  weight  of  the  limb,  which  causes  the 
helpless  member  to  roll  out,  aided  probably  by  the 
action  of  the  external  rotator  muscles. 

Certain  spiral  fractures  (helicoidal  fractures 
of  Leriche)  may  be  produced  in  the  lower  part  of 
the  shaft  as  the  result  of  torsion.  M.  Fere  finds 
by  experiment  that  if  the  limb  be  carried  forwards 
in  front  of  the  opposite  knee,  and  the  foot  rotated 
outwards,  a  spiral  fracture  can  be  produced  at  the 
junction  of  the  lower  and  middle  thirds  of  the 
femur.  A  like  fracture  at  the  same  level,  but 
with  the  direction  of  the  spiral  reversed,  can  be 
produced  by  carrying  the  limb  outwards  and  then 
rotating  it  inwards. 

Shortening  of  the    limb  after  fracture.— 
It  is  doubtful  if  a  fracture  of  the  shaft  of  the 
femur   can,    after   any   treatment,    become   united 
without  some  shortening  resulting,  save  in  a  few 
exceptional  cases.     It  is  important,  in  connection 
with   this    subject,    to    remember    that    the    lower 
limbs  may  be   normally  of   unequal   length.     Dr. 
Wight,    of   Brooklyn,    has   fully   investigated   this 
matter,    and   has    arrived   at   the    following   con- 
clusions :  (1)  The  greater  number  of  normal  lower 
limbs  are  of  unequal  length  ;    (2)   the   left  limb  is 
often    longer  than   the   right ;    (3)  the   average   in- 
equality of  normal  lower  limbs  is  probably  about  \ 
of  an  inch ;  (4)  the  average  amount  of  shortening 
after  a  fracture  of  the  femur  that  has  been  well 
treated  is  about  f  of  an  inch  ;  (5)  in  about  one  case 
in  ten  or  eleven  the  two  limbs  will  be  found  to  be 
of  equal  length  after  the  union  of  the  fracture ; 
(6)  one  limb  can  never  be  a  certain  standard  of 
length  for  the  opposite  limb.     Dr.   Garson,   as  a 


Chap.  XX]  THE    THIGH  521 

result  of  the  careful  examination  of  some  seventy 
skeletons,  states  that  both  the  lower  limbs  are  of 
equal  length  in  only  about  10  per  cent,  of  all  cases. 
He  also  found  that  the  femur  was  more  frequently 
the  seat  of  variation  than  the  tibia. 

Amputation    of   the    tliigli. — In  a  circular 
amputation  of  the  thigh  about  its  middle  the  fol- 


2  $ 

Fig.  S4. — Transverse  section  through  the  middle  of  the  thigh.    (Brawne.) 

«,  Rectus  fenioris;  l>.  vastus  extemus;  c,  crureus;  d,  vastus  internus;  e,  short 
head  i if  biceps;  /.  long  head  of  biceps  ;  (i.  seinitendinosus  ;  h,  semimembra- 
nosus ;  i,  adductor  niaguus ;  j,  gracilis ;  k,  adductor  longus ;  I,  sartorius.  1, 
femoral  artery  :  i',  great  sciatic  nerve  ;  3,  great  saphenous  veiu :  4,  middle 
cutaneous  nerve:  5,  external  cutaneous  nerve;  6,  perforating  branches  from 
profunda  ;  7,  small  sciatic  nerve. 

lowing  parts  would  be  divided  (Fig.  84)  :  the 
quadriceps,  sartorius,  gracilis,  long  and  great  ad- 
ductors, and  the  three  hamstring  muscles;  the 
superficial  and  deep  femoral  vessels,  the  descend- 
ing branches  of  the  external  circumflex  artery,  the 
lower  perforating  vessels,  and  the  long  saphenous 
vein ;  the  main  branches  of  the  anterior  crural 
nerve  (middle  cutaneous,  internal  cutaneous,  and 
muscular,  together  with  the  long  saphenous  nerve), 
the    anterior    branch    of    the    external    cutaneous 


522  SURGICAL   APPLIED    ANATOMY      [Part  V 

nerve,  the  obturator,  and  the  great  and  small 
sciatic  nerves.  Owing  to  the  unequal  manner  in 
which  the  divided  muscles  retract,  a  simple  cir- 
cular amputation  is  not  well  adapted  for  the 
thigh.  A  more  convenient  method  of  amputation 
is  represented  bv  the  elliptical  method,  the  lower 
extremity  of  the  ellipse  being  on  that  side  of  the 
limb  on  which  muscular  retraction  is  the  more 
marked,  i.e.  on  the  posterior  side  of  the  thigh. 


& 


CHAPTER  XXI 

THE  REGION  OF  THE  KNEE 

In  this  chapter  will  be  considered  the  articulation 
of  the  knee,  the  soft  parts  about  the  joint,  the 
popliteal  space,  the  lower  end  of  the  femur,  the 
patella,  and  the  upper  ends  of  the  tibia  and  fibula. 

Surface  anatomy. — In  the  front  of  the  knee 
the  patella  can  be  distinctly  felt  and  seen.  Its 
inner  border  is  a  little  more  prominent  than  the 
outer.  When  the  limb  lies  in  the  extended  pos- 
ture, with  the  quadriceps  relaxed,  the  patella  can 
be  moved  to  and  fro,  and  appears  to  be  but  loosely 
attached.  When  the  quadriceps  is  contracted  the 
bone  is  drawn  upwards,  and  becomes  firmly  fixed 
against  the  femur.  In  flexion  of  the  joint  the 
patella  sinks  into  the  hollow  between  the  tibia  and 
the  intercondyloid  notch,  and  is  very  firmly  fixed. 
In  this  position  some  part  of  the  trochlear  surface 
of  the  femur  can  be  made  out  above  the  patella. 
On  each  side  of  the  knee-cap  a  hollow  exists  which 
may  be  completely  filled  up  with  fat  in  the  obese. 

When  the  limb  lies  in  the  extended  posture  the 
ligamentum  patellae  is  not  to  be  very  distinctly 
made  out.  It  becomes  a  little  more  conspicuous 
in  the  flexed  position,  and  is  most  prominent  when 
the  quadriceps  muscle  is  vigorously  contracted. 
The  subpatellar  pad  of  fat  bulges  outwards  on 
each  side  of  the  ligament  and  may  be  mistaken 
by  the  inexperienced  for  fluid  in  the  joint. 

On  the  inner  side  of  the  knee  the  following 
parts    can    be    felt    from    above    downwards  :    the 

523 


524  SURGICAL    APPLIED    ANATOMY     [Part  V 

• 
tubercle  for  the  adductor  magnus,  and  the  tendon 
of  insertion  of  that  muscle;  the  inner  condyle  of 
the  femur,  which  is  very  prominent,  and  forms 
the  chief  part  of  the  rounded  eminence  on  this 
aspect  of  the  joint;  and  below  this  the  inner 
tuberosity  of  the  tibia.  Between  the  two  latter 
processes  of  bone,  the  interarticular  line  and 
semilunar  cartilage  are  easily  felt.  On  the  outer 
side  of  the  joint  is  the  external  condyle  of  the 
femur,  which  is  much  less  conspicuous  than  its 
fellow  of  the  opposite  side,  and  below  it  is  the 
corresponding  tuberosity  of  the  tibia,  forming  a 
marked  prominence.  Immediately  in  front  of  the 
biceps  tendon  the  upper  part  of  the  external 
lateral  ligament  can  be  felt  when  the  joint  is  a 
little  flexed.  Between  the  tendon  and  the  patella, 
the  lower  part  of  the  ilio-tibial  process  of  the 
fascia  lata  can  be  detected  as  a  prominent  rounded 
band,  descending  to  the  external  tuberosity  of  the 
tibia.  It  is  most  distinct  when  the  knee-joint  is 
forcibly  extended  by  muscular  action,  and  often 
stands  out  conspicuously  beneath  the  skin.  The- 
tubercle  of  the  tibia  and  the  head  of  the  fibula  are- 
both  readily  felt,  and  are  nearly  on  the  same  level. 

The  popliteal  space  only  appears  as  a  hollow 
when  the  knee  is  bent.  In  the  extended  limb  the 
hollow  is  replaced  by  an  evenly  rounded  eminence. 
The  crease  in  the  skin  that  passes  transversely 
across  the  ham  is  some  way  above  the  line  of  the 
knee-joint.  On  the  outer  side  of  the  space  the 
biceps  tendon  can  be  very  readily  felt,  especially 
when  the  muscle  is  in  action.  Just  behind  it,  and 
along  its  inner  border,  lies  the  peroneal  nerve. 
It  can  be  rolled  under  the  finger  as  it  crosses  the 
head  of  the  fibula  to  pass  beneath  the  peroneus 
longus  muscle.  On  the  inner  side  of  the  ham 
three  tendons  can  be  felt.  Nearest  to  the  middle 
of  the  space  is  the  long  prominent  tendon  of  the 
semitendinosus.  Internal  to  it  is  the  larger  and 
less  distinct  semimembranosus  tendon,  and  still 
more  to  the  inner  side  the  gracilis  may  be  made  out. 

The  popliteal  vessels  enter  the  ham  obliquely 


Chap.  XXI]        EEGION   OF   THE    KNEE  525 

at  its  upper  and  inner  part,  and  under  cover  of 
the  semimembranosus  muscle.  The  outer  border 
of  this  muscle  is  the  guide  to  the  upper  portion 
of  the  artery.  The  vessels  in  their  descent  reach 
a  point  behind  the  middle  of  the  knee-joint,  and 
then  pass  vertically  downwards.  The  termination 
of  the  popliteal  artery  is  on  a  level  with  the  lower 
part  of  the  tubercle  of  the  tibia.  When  the  limb 
is  flexed,  the  pulsations  of  the  artery  can  be  felt 
and  the  vessel  compressed  against  the  femur  a 
little  below  its  point  of  entry  into  the  popliteal 
space.  The  upper  articular  arteries  run  trans- 
versely inwards  and  outwards  just  above  the 
femoral  condyles.  The  lower  articular  arteries 
are  also  placed  transversely,  the  inner  vessels  run- 
ning just  below  the  internal  tuberosity  of  the 
tibia,  and  the  outer  just  above  the  head  of  the 
fibula.  The  deep  branch  of  the  anastomotica 
magna  descends  to  the  inner  condyle  of  the  femur 
in  the  substance  of  the  vastus,  internus,  and  along 
the  front  of  the  adductor  magnus  tendon.  The 
internal  saphenous  vein  passes  up  along  the  back 
part  of  the  internal  condyle  of  the  femur,  and 
then  follows  the  sartorius  muscle  to  the  thigh. 
It  is  just  below  the  interarticular  line  that  the 
long  saphenous  nerve  usually  joins  the  vein.  The 
short  saphenous  vein  follows  the  middle  line  of  the 
calf  just  below  the  ham,  and  pierces  the  deep 
fascia  at  the  lower  part  of  the  popliteal  space. 
Tnis  vessel  is  much  less  conspicuous  than  is  the 
long  saphenous  vein,  and  is,  indeed,  not  often  to 
be  seen  unless  varicose. 

_  The  internal  popliteal  nerve  descends  in  the 
middle  line,  and  continues  the  line  that  marks  the 
course  of  the  great  sciatic  trunk. 

In  their  normal  condition  the  popliteal  glands 
are  not  to  be  felt. 

The  limits  of  the  synovial  membrane  of  the 
knee-joint,  and  the  position  of  the  various  bursa? 
about  this  articulation,  will  be  dealt  with  in  some 
of  the  subsequent  paragraphs. 

The  front    of  the  "knee.— The  skin  over  the 


526  SUKGICAL   APPLIED    ANATOMY     [Part  V 

front  of  the  knee  is  dense  and  very  movable.  This 
mobility  affords  considerable  protection  to  the 
knee-Joint,  especially  in  stabs  with  bluntish  in- 
struments, and  in  any  injury  where  the  gliding 
movement  of  the  skin  may  direct  the  violence  away 
from  the  articulation.  The  comparative  looseness 
of  the  integument  is  sometimes  utilised  in  the 
operation  of  removing  so-called  "  loose  cartilages  '; 
from  the  knee-joint.  It  permits  the  incision  into 
the  joint  to  be  very  indirect,  and,  the  skin  being 
dragged  out  of  place  during  the  operation,  it 
follows  that,  when  the  procedure  is  complete,  the 
surface  wound  and  that  in  the  knee  capsule  no 
longer  correspond.  In  flexion,  the  skin  is  drawn 
tightly  over  the  patella,  and,  as  is  the  case  else- 
where, where  the  integument  lies  more  or  less 
directly  upon  the  bone,  a  contusion  over  the  knee- 
cap may  produce  a  lesion  precisely  like  an  in- 
cised wound. 

In  the  Lancet  for.  1877  is  recorded  the  case  of 
a  very  stout  woman,  aged  fifty-seven,  who,  'stum- 
bling on  a  hard  road,  fell  upon  her  bent  knee. 
The  skin  was  burst  across  the  front  of  the  knee, 
and  a  wound  was  produced  that  was  7  inches  in 
length,  and  was  as  cleanly  cut  as  if  made  by  a. 
scalpel. 

There  is  but  little  subcutaneous  fat  in  front  of 
the  articulation,  and  thus  it  happens  that  in  am- 
putations through  the  knee-joint  the  anterior  flap 
is  very  thin,  and  is  composed  of  little  other  than 
the  simple  integument. 

As  blisters,  and  various  forms  of  counter- 
irritant,  are  often  applied  to  the  front  of  the  knee 
in  cases  of  disease,  it  may  be  well  to  take  note  of 
the  blood-supply  of  this  part,  and  of  the  relations 
between  the  surface  vessels  and  nerves  and  those  of 
the  joint.  The  vessels  that  give  branches  to  the 
front  of  the  knee,  and  are  concerned  in  the 
suppjy  of  the  part  to  which  blisters  are  usually 
applied,  are  the  anastomotic,  the  four  articular 
branches  of  the  ponliteal,  and  the  anterior  tibial 
recurrent.     Now  of  these  arteries,  and  especially 


Chap.  XXI]        REGION   OF   THE    KNEE  527 

of  the  anastomotica  magna  and  superior  articular, 
it  may  be  said  that,  shortly  after  their  origin, 
they  divide  into  two  branches,  or  two  sets  of 
branches,  one  going  to  the  surface  and  the  other 
to  the  articulation  of  the  knee  and  deeper  parts 
about  it.  It  may  be  supposed,  therefore,  that,  in 
applying  a  counter-irritant  in  front  of  the  knee 
for  the  relief  of  a  joint  affection,  a  greatly  in- 
creased quantity  of  blood  is  drawn  into  the  super- 
ficial divisions  of  the  above-named  vessels,  and  less 
blood  is  thereby  left  to  flow  by  their  deeper 
branches  to  the  seat  of  disease.  The  skin  over  the 
front  of  the  knee,  the  anterior  parts  of  the  joint, 
and  the  quadriceps  is  supplied  from  the  third  and 
fourth  lumbar  segments  through  branches  of  the 
anterior  crural  and  obturator  nerves. 

The  superficial  lymphatics  in  the  region  of  the 
knee  lie  for  the  most  part  on  the  inner  aspect  of 
the  joint,  and  follow  the  course  of  the  long 
saphenous  vein.  Ulcers,  and  other  inflammatory 
affections  of  the  skin  over  the  articulation,  are 
more  apt  to  be  associated  with  lymphangitis  and 
with  enlargement  of  the  inguinal  glands  when 
situate  on  the  inner  aspect  of  the  joint  than  when 
placed  in  front  or  to  the  outer  side  of  it. 

The  bursae  over  the  front  of  the  knee. — (1) 
The  patellar  bursa  is  a  large  sac  placed  in  front 
of  the  patella  and  upper  part  of  the  patellar  liga- 
ment, and  separates  those  structures  from  the 
skin.  It  is  frequently  divided  by  septa  into 
superficial  and  deep  compartments.  It  is  very 
often  found  enlarged  in  those  who  kneel  much, 
in  housemaids,  stonemasons,  religieuses,  etc.  The 
parts  about  are  well  supplied  with  nerves,  and 
hence  much  pain  is  usually  associated  with  acute 
inflammation  of  this  sac.  It  is  in  close  contact 
with  the  patella,  and,  in  one  case  reported  by 
Erichsen,  suppuration  of  the  bursa  led  to  caries 
of  that  bone  (Figs.  85,  86,  and  90).  (2)  There  is 
a  bursa  between  the  patellar  ligament  and  the 
tubercle  of  the  tibia  (Figc.  86).  When  inflamed, 
it  causes  more  pain  than  is  observed  in  affections 


528  SURGICAL    APPLIED    ANATOMY      [Part  V 

of  the  previous  bursa,  since  it  is  firmly  compressed 
between  two  rigid  structures,  the  ligament  and  the 
bone.  It  is  separated  from  the  synovial  cavity 
by  the  pad  of  fat  that  lies  behind  the  patella. 
(3)  The  bursa  between  the  quadriceps  tendon  and 
the  femur  will  be  considered  in  connection  with 
the  synovial  cavity. 

The  popliteal  space.  —  The  skin  over  the 
space  is  not  so  movable  as  is  that  over  the  front 
of  the  knee.  When  destroyed  by  injury,  by  burns, 
or  by  extensive  ulceration,  the  contraction  of  the 
resulting  cicatrix  may  lead  to  a  rigidly  bent 
knee.  The  skin  in  this  place  has  also  been  rup- 
tured by  forcible  extension  applied  to  the  limb  in 
cases  of  contracted  knee.  Beneath  the  skin  and 
superficial  tissue  is  the  popliteal  fascia,  a  dense 
membrane  that  covers  in  the  space.  It  is  but 
a  continuation  of  the  fascia  lata  of  the  thigh, 
and  is  continuous  below  with  the  fascia  of  the  leg. 
It  passes  without  bony  attachment  over  the  ham1 
string  muscles  that  bound  the  ham.  This  fascia 
limits,  often  in  a  very  marked  manner,  the  pro- 
gress of  popliteal  abscesses  and  growths  towards 
the  surface.  Its  unyielding  character  is  fa  prime 
cause  in  the  production  of  the  severe  pain  with 
which  such  collections  and  tumours  are  often 
associated.  The  popliteal  abscess,  unable  to  reach 
the  surface,  is  encouraged  to  extend  either  up 
into  the  thigh  or  down  the  leg.  The  ham  may 
hold  a  very  considerable  quantity  of  pus.  Vel- 
peau  has  seen  a  case  where  a  litre  (1  pint,  15  oz.) 
of  pus  was  evacuated  from  this  region  in  a 
patient  who  presented  before  the  operation  but  an 
insignificant  swelling  in  the  site  of  the  collection. 
Duplay  records  two  cases  of  ulceration  of  an  ab- 
scess into  the  popliteal  artery,  and  Ollivier  an 
instance  where  the  abscess,  unable  to  find  a  way  to 
escape,   ultimately  entered  the  knee-joint. 

Pus  may  reach  the  ham  from  the  buttock  or 
pelvis  bv  following  the  great  sciatic  nerve,  or  may 
extend  from  the  thigh  through  the  opening  in  the 
great  adductor  for  the  femoral  vessels. 


Chap.  XXI]       REGION   OF   THE    KNEE  529 

The  Ii  a  in  string  muscles  are  frequently 
found  contracted  in  neglected  cases  of  knee-joint 
disease,  and  produce  thereby  more  or  less  rigid 
flexion  of  the  leg  upon  the  thigh.  Irritation  from 
disease  of  the  knee-joint  may  lead  to  contracture 
of  the  hamstring  muscles.  These  muscles  are  sup- 
plied through  the  great  sciatic  nerve  from  the 
fifth  lumbar  segment,  from  which  the  knee-joint 
derives  in  part  its  nerve  supply.  Muscles  on  the 
flexor  aspect  of  a  bent  joint  undergo  a  permanent 
shortening  if  the  position  be  maintained  for  a  con- 
siderable space  of  time. 

Contraction  of  these  muscles  in  knee-joint  dis- 
ease tends  not  only  to  flex  the  knee  but  also  to 
draw  the  tibia  backwards,  and  produce  in  some 
cases  a  partial  luxation. 

The  hamstring  tendons  may  be  ruptured  by 
violence,  the  tendon  most  frequently  torn  being 
that  of  the  biceps.  The  muscles  <  are  greatly 
stretched  when  the  trunk  is  bent  forcibly  forwards 
at  the  hip-joint,  the  knee  remaining  extended. 
Extreme  movement  in  this  position  has  ruptured 
some  of  the  fibres  of  this  muscle.  The  difficulty 
experienced  in  touching  the  toes  with  the  fingers 
while  the  knees  are  kept  stiff  depends  upon  the 
resistance  offered  by  the  stretched  hamstrings.  In 
tenotomy  of  the  biceps  tendon  the  peroneal  nerve 
is  in  great  risk  of  being  wounded.  It  may  be 
noted  that  contraction  of  the  muscle  tends  to  in- 
crease the  distance  between  the  tendon  and  the 
nerve,  and  to  render  the  former  more  superficial. 
The  peroneal  nerve  may  be  compressed  by  band- 
ages or  garters  applied  too  tightly  over  the  head 
or  neck  of  the  fibula. 

The  vessels  of  the  ham.-— The  popliteal  ves- 
sels are,  from  their  depth,  but  seldom  wounded. 
It  must  be  borne  in  mind  that  the  lower  part  of 
the  artery  may  be  reached  from  the  anterior 
aspect  of  the  leg  by  an  instrument  passing  between 
the  tibia  and  fibula.  Thus  Spence  reports  the 
case  of  a  farmer  who  received  a  wound  in  front 
of  the  leg,  just  below  the  knee,  from  the  slipping 
2  i 


530  SURGICAL   APPLIED   ANATOMY      [Part  V 

of  his  knife  while  cutting  a  stick.  It  was  dis- 
covered subsequently  that  the  knife  had  entered 
the  interosseous  space  and  had  wounded  the  pop- 
liteal artery  at  its  bifurcation.  It  had  indeed 
nearly  severed  the  anterior  tibial  artery  from  the 
main  trunk. 

The  popliteal  artery  has  been  ruptured  by  ex- 
ternal violence,  as  when  a  wheel  has  passed  over 
the  region  of  the  vessel.  This  artery  is  more  fre- 
quently the  seat  of  aneurism  than  is  any  other 
artery  in  the  body,  save  only  the  thoracic  aorta. 
In  551  cases  of  spontaneous  aneurism,  collected 
by  Crisp,  the  popliteal  vessel  was  the  seat  of  the 
disease  in  137  instances,  the  thoracic  aorta  having 
been  affected  in  175  of  the  cases.  This  marked 
disposition  to  aneurism  depends  upon  many 
factors.  The  vessel  is  subjected  to  a  great  deal 
of  movement,  and  often  to  very  violent  movement. 
Experiments  upon  the  dead  body  show  that  the 
inner  and  middle  coats  of  the  vessel  may  be  rup- 
tured by  extreme  flexion  of  the  knee,  and  that  a 
like  rupture  may  in  a  smaller  percentage  of  cases 
be  brought  about  by  forcible  extension.  More- 
over, except  when  the  limb  is  in  the  position  of 
extension,  the  popliteal  artery  is,  like  the  thoracic 
aorta,  much  curved.  Then,  again,  the  vessel 
breaks  up  into  two  large  vessels,  and  it  is  well 
known  that  the  point  of  bifurcation  of  an  artery 
is  a  favourite  spot  for  aneurism.  Lastly,  the 
artery  is  supported  only  by  the  lax  tissue  of  the 
popliteal  space,  and  the  support  of  strong  muscles 
given  elsewhere  to  so  many  large  vessels  is  practic- 
ally absent.  Some  popliteal  aneurisms  have  been 
successfully  treated  by  flexing  the  knee  and  retain- 
ing the  limb  for  some  time  in  that  position.  That 
flexion  can  have  a  direct  effect  upon  the  lumen  of 
the  vessel  is  shown  by  the  diminished  pulse  at  the 
inner  ankle  produced  by  forcibly  bending  the  leg 
upon  the  thigh.  The  artery  and  vein  are  so 
adherent  that  it  is  difficult  to  separate  the  two 
when  applying  a  ligature  to  the  arterial  trunk. 
This  adhesion  must  have  been  appreciated  by  any 


Chap.  XXI]        REGION    OF    THE    KNEE  531 

who  have  taken  pains  to  "  clean  "  the  artery  in  a 
dissection  of  the  ham. 

The  popliteal  vein  is  a  remarkably  substantial 
vessel,  and  has  walls  so  dense  and  thick  that  on 
section  they  often  look  more  like  the  tunics  of  an 
artery.  On  the  ground  of  this  peculiarity,  and  of 
its  close  adhesion  to  its  companion  vessel,  Tillaux 
asserts  that  "  it  is  unlike  any  other  vein  in  the 
economy/'  It  is  worthy  of  note  that  the  vein, 
although  more  superficial  than  the  artery,  is  very 
rarely  ruptured  by  violence.  As  a  rule,  the  artery 
alone  is  torn.  In  a  few  cases  both  the  vessels 
may  suffer;  but  I  can  find  no  instance  recorded 
of  rupture  of  the  popliteal  vein  alone. 

From  the  relations  of  the  artery  to  the  vein 
and  nerve  it  will  be  understood  that  a  popliteal 
aneurism  may  soon  lead  to  oedema  of  the  leg  and 
to  nerve  symptoms  depending  upon  pressure  on 
the  internal  popliteal  trunk.  It  has  more  than 
once  also  made  its  way  into  the  knee-joint,  with 
the  posterior  ligament  of  which  the  artery  is  in 
such  close  relation. 

The  short  saphenous  vein  lies  almost  in  the 
middle  line,  and,  not  being  usually  apparent 
through  the  skin,  may  be  divided  in  an  incision 
made  into  the  lower  part  of  the  popliteal  space. 

The  lymphatic  glands  in  the  ham  are  from 
four  to  five  in  number  and  are  deeply  placed 
about  the  great  vessels.  When  enlarged  they  have 
been  mistaken  for  aneurism  and  other  popliteal 
tumours.  They  receive  the  deep  lymphatics  of 
the  leg.  A  small  gland  is  often  met  with  beneath 
the  fascia,  close  to  the  point  of  entry  of  the  short 
saphenous  vein.  It  receives  some  lymphatics  that 
follow  that  vessel. 

The  bmsae  about  the  ham  are  usually  seven 
in  number,  four  on  the  inner  side  of  the  space 
and  three  on  the  outer.  Inner  side. — (1)  A  large 
bursa  between  the  internal  condyle  of  the  femur 
and  the  inner  head  of  the  gastrocnemius  and  the 
semimembranosus.  This  is  the  largest  bursa  in 
the  space,  and  after  adult  life  it  usually  communi- 


532  SURGICAL    APPLIED    ANATOMY      [Part  V 

cates  with  the  joint.  It  is,  of  all  the  bursas  in 
this  region,  the  one  most  often  enlarged,  and 
when  affected  may  attain  great  size.  In  one  re- 
ported case  the  sac  measured  5  by  3.5  inches. 
In  the  extended  position  of  the  limb  the  enlarged 
bursa  feels  firm  and  resistant,  but  on  flexion  it 
becomes  flaccid  and  can  often  be  made  to  entirely 
disappear.  Probably  the  slit-like  communication 
between  the  bursa  and  the  joint  is  closed  when 
the  posterior  ligament  is  tightened  by  extension, 
and  is  opened  when  it  is  relaxed  on  bending  the 
knee.  In  the  latter  posture  the  contents  of  the 
bursa  can  be  reduced  into  the  cavity  of  the  knee- 
joint,  and  so  the  tumour  disappears.  (2)  A  little 
bursa  between  the  semimembranosus  tendon  and 
the  tuberosity  of  the  tibia.  Rather  below  the 
level  of  the  knee  there  are  two  further  bursas — (3) 
one  beneath  the  insertion  of  the  sartor ius,  and 
(4)  another  beneath  the  insertions  of  the  gracilis 
and  semitendinosus.  Outer  side. — (l)  A  large 
diverticulum  of  the  synovial  membrane  of  the 
joint  between  the  popliteus  tendon  and  the  ex- 
ternal tuberosity  of  the  tibia.  This  diverticulum 
serves  the  purpose  of  a  bursa,  and  may  open  into 
the  tibio-fibular  articulation,  and  so  bring  that 
cavity  into  connection  with  the  knee-joint.  (2)  A 
bursa  between  the  outer  head  of  the  gastrocnemius 
and  the  femoral  condyle.  It  is  not  constant  and 
is  not  connected  with  the  articulation.  (3)  A 
bursa  between  the  biceps  tendon  and  the  external 
lateral  ligament.  The  peroneal  nerve  runs  across 
this  sac,  a  circumstance  that  may  explain  some  of 
the  pain  experienced  when  the  bursa  is  enlarged. 

It  is  not  improbable  that  wounds  in  this  region 
of  bursae  containing  fluid  have  been  mistaken  for 
wounds  of  the  joint,  and  the  escaping  serum  for 
synovia. 

The  kiico-joint.  —  This  articulation  is  the 
largest  in  the  body.  The  joint  owes  its  great 
strength  to  the  powerful  ligaments  that  unite  the 
two  component  bones,  and  especially  to  the  muscles 
and    fasciae    that    surround     it.     It    derives    no 


Chap.  XXI]       REGION   OF   THE    KNEE 


533 


strength  from  the  shape  of  the  articular  surfaces, 
since  they  are  merely  placed  in  contact  with  one 
another.  In  spite  of  its  frequent  exposure  to  in- 
jury, dislocations  at  the  knee  are  extremely  rare. 
The  lateral  ligaments  are  comparatively  feeble, 
are  tense  in  extension  and  relaxed  in  flexion. 
The  laxity  of  these  ligaments  is  such  that  partial 


Fig.  85. — Vertical  section  of  normal  knee-joint.    (Braune.) 

a,  Quadriceps;  l>,  semimembranosus:  c,  gastrocnemius;  d.  posterior  crucial  liga- 
ment ;  c,  ligamentum  patellae ;  /,  bursa  between  quadriceps  and  femur. 


luxations  of  the  tibia  are  possible  without  rup- 
ture of  these  bands,  especially  in  cases  where  the 
joint  is  found  slightly  flexed  after  the  accident. 
The  crucial  ligaments  are  very  powerful,  and  are 
more  or  less  tense  in  all  positions  of  the  joint. 
The  anterior  of  these  ligaments  especially  resists 
extension,  forward  displacement  of  the  tibia,  and 
rotation  inwards  of  the  leg.  The  posterior  band 
resists  flexion  and  displacement  backwards  of  the 


534  SURGICAL    APPLIED    ANATOMY      [fart  V 

tibia.  In  the  movement  of  extension  the  tibia 
slides  a  little  forwards  and  is  rotated  a  little  out- 
wards. In  flexion  that  bone  glides  backwards  and 
rolls  a  little  inwards.  Extension  generally  is 
limited  by  the  crucial  and  posterior  ligaments; 
flexion  by  the  ligamentum  patellae  and  anterior 
part  of  the  capsule,  in  addition  to  the  crucial 
ligaments.  Rotation  is  possible  only  in  the  flexed 
position.  The  thinnest  part  of  the  posterior  liga- 
ment is  the  portion  below  the  oblique  fibres  de- 
rived from  the  semimembranosus.  If  pus  finds 
its  way  from  the  joint  into  the  ham,_  it  will 
probably  escape  through  this  part  of  the  ligament. 

In  the  contracted  knee  associated  with  fibrous 
ankylosis,  the  chief  contraction,  so  far  as  the 
joint  tissues  are  concerned,  is  in  the  posterior 
ligament,  in  the  lateral  ligaments,  and  in  the 
fibrous  and  fatty  tissue  between  the  former  liga- 
ment and  the  posterior  crucial  band. 

The  synovial  membrane  of  the  knee-joint  ex- 
tends upwards  as  a  large  cul-de-sac  above  the 
patella  and  beneath  the  extensor  tendon.  This 
cul-de-sac  reaches  a  point  an  inch  or  more  above 
the  upper  margin  of  the  trochlear  surface  on  the 
femur,  and  is  rendered  very  distinct  when  the 
joint  is  distended  with  fluid  (Fig.  86).  When  the 
knee  is  bent  the  cul-de-sac  is  drawn  down,  and 
therefore  this  position  of  the  limb  is  advised 
when  operations  are  about  to  be  performed  upon 
the  lower  end  of  the  femur.  Above  the  synovial 
pouch  is  a  bursa  that  separates  the  quadriceps 
tendon  from  the  femur,  and  is  usually  over  an 
inch  in  its  vertical  measurement  (Fig.  86).  From 
the  examination  of  two  hundred  and  sixty  knee- 
joints  in  both  infants  and  adults,  Schwartz  found 
that  this  bursa  communicated  with  the  synovial 
cavity  in  seven  cases  out  of  ten  in  young  children, 
and  in  eight  cases  out  of  ten  in  adults. 

It  will  thus  be  seen  that  when  this  communica- 
tion exists,  a  stab  over  the  femur,  about  2  inches 
above  the  trochlear  surface  of  the  bone,  or  about 
the  same   distance   above  the  top   of  the  patella, 


Chap.  XXI]        REGION   OF   THE    KNEE 


535 


when  the  limb  is  extended,  will  practically  open 
the  knee-joint. 

Cases  are   reported  of  extravasation   of  blood 
into  this  bursa  that,   although  at  first  limited  to 


I  ill  M 


mm 
m 


Fig.  S6. — Vertical  section  of  knee-joint  distended  with  fluid.   (Braunc.) 

a,  Vastus  externus ;  b,  crureus ;  c,  short  head,  ami  d,  long  head,  of  biceps  ;  e,  plan- 
taris  ;  /,  gastrocnemius ;  </,  popliteus ;  //,  soleus ;  i,  tibialis  posticus ;  j,  bursa 
patella?:  k,  liganientuni  patella);  I,  liu-aniontmn  mucosum  ;  in,  anterior  crucial 
ligament:  n,  external  semilunar  cartilage.  1,  external  popliteal  nerve; 
2,  popliteal  artery. 

the  sac,  have,  on  rough  handling,  extended  into 
the  knee-joint,  a  circumstance  leading  to  the  sup- 
position that  in  some  cases  the  orifice  of  communi- 
cation may  be  very  small. 

The  crucial  ligaments,  although  more  or  less 
completely  invested  by  the  synovial  membrane, 
are  yet  entirely  outside  the  synovial  cavity,  and 


536  SURGICAL    APPLIED    ANATOMY     [Part  V 

divide  the  cavity  behind  into  an  outer  and  an  inner 
condylar  recess.  The  posterior  ligament  is  con- 
tinuous with  the  posterior  part  of  the  capsule. 

The  upper  third  of  the  patellar  ligament  is  in 
relation  to  the  synovial  membrane,  from  which, 
however,  it  is  separated  by  a  pad  of  fat.  The 
lower  two-thirds  of  the  ligament  are  in  relation 
to  the  bursa  and  fatty  tissue  that  intervene  be- 
tween the  band  and  the  tibia.  A  knife  passed 
horizontally  backwards  at  the  apex  of  the  patella 
would,  when  the  limb  is  extended,  just  miss  the 
joint  line  between  the  femur  and  tibia,  and  would 
hit  the  latter  bone  (Fig.  85).  If,  however,  there 
be  any  effusion  in  the  joint,  or  the  limb  be  a  little 
flexed,  a  knife  so  introduced  would  pass  between 
the  two  bones  (Fig.  86).  Fringes  of  the  synovial 
membrane  (the  alar  ligaments)  fill  the  intervals 
between  the  articular  surfaces  of  the  patella  and 
femur.  Villous  processes  may  grow  out  from 
them,  become  detached,  and  form  loose  bodies  in 
the  joint.  That  such  processes  should  undergo 
chondrification  and  form  cartilaginous  bodies  is 
not  surprising  seeing  that  the  synovial  lining  is 
derived  from  the  same  tissue  as  forms  the  articular 
surfaces  of  the  bones  and  is  in  reality  merely  a 
finely  spread  layer  of  cartilage  covering  a  fibrous 
membrane. 

Joint  disease—Owing  to  its  superficial 
position  the  knee-joint  is  the  articulation  that  is 
most  frequently  the  seat  of  inflammation  due  to 
injury  and  exposure  to  cold.  When  distended 
with  fluid,  the  effusion  soon  shows  itself  above 
and  at  the  sides  of  the  patella,  by  bulging  for- 
ward the  synovial  sac,  which  is  here  more  nearly 
in  relation  to  the  surface  than  it  is  elsewhere. 
Fluctuation  is  soon  to  be  detected,  and  the  patella, 
being  pushed  away  from  the  femur,  is  said  to 
"  float  *'  upon  the  distending  fluid  (Fig.  86). 

The  inflamed  knee-joint,  if  left  to  itself,  almost 
invariably  assumes  the  flexed  position.  This  may 
be  explained  upon  three  hypotheses,  and  it  is 
probable  that  each  of  the  three  reputed     factors 


Chap.  XXI]       REGION   OF   THE    KNEE 


537 


takes  part  in  producing  this  position  in  cases  of 
disease. 

(1)  The  capacity  of  the  joint  is  increased  on 
flexion.  The  pain  of  acute  synovitis  is  due  mainly 
to  the  increasing  distension  of  the  joint  with  fluid, 
and  it  is  natural  that  the  patient  should  in- 
stinctively place  the  limb  in  the  position  in  which 
the  joint  will  hold  the  greatest  amount  of  fluid, 
and  in  which  the  interarticular  tension  is  reduced 
to  a  minimum.  Braune  found  that  the  maximum 
capacity  was  reached  when  the  knee  was  flexed  25°, 
and  the  minimum  on  complete  flexion. 


Ti^Ans verse  Lie, 


COROflARy  Lie 


Exter/halSemil 

ArtT.CEUCIAL 

popliteus-, 
Ext.Lat.Lic^ 

5ICEP5 


LiQAMEmuM  Patellae 
A/nt    ftotzn 

kC0R0/iARy  Liq. 

\ 

LilrtTERftALSEAflLU/IAR 

Cartilaqe 

Internal  Lateral 
L.q. 


ST.  Crucial  Lie 
Post.  Liq. 

Fig.  ST.— Illustrating  the  fixation  and  movements  of  the  semilunar 

cartilages. 

The  positiou  of  the  internal  semilunar  cartilage,  when  the  tibia  is  rotated  out- 
wards or  femur  inwards,  is  shown  in  red. 

(2)  By  flexing  the  limb,  the  more  powerful 
ligaments  (such  as  the  ligamentum  posticum,  the 
posterior  crucial  and  lateral  ligaments)  are  re- 
laxed, while  the  ligaments  rendered  tense  by  the 
position  are  the  patellar  and  the  anterior  part  of 
the  capsular,  the  latter  of  which  is  but  a  yielding 
membrane. 

(3)  The  sensory  nerves  of  the  joint  being  dis- 
turbed, contraction  of  muscles  may  be  anticipated 
from  reflex  action,  and  of  the  muscles  so  excited 
the  flexors  may  be  expected  to  have  the  advantage, 
as  being  the  more  powerful  and  the  more  favour- 
ably placed  for  acting  upon  the  articulation. 

Dislocation  of  the  semilunar  cartilages,— 


538  SURGICAL   APPLIED   ANATOMY     [Part  V 

One  or  other  of  these  cartilages  may  be  displaced 
from  its  attachments  to  the  tibia,  and  become 
nipped  or  locked  between  that  bone  and  the  femur. 
The  result  is  a  sudden  pain  in  the  limb,  associated 
with  a  fixing  of  the  knee  in  a  flexed  position. 
The  accident  is  usually  brought  about  by  a  twist 
given  to  the  leg  when  the  knee-joint  is  more  or  less 
bent.  In  200  cases  of  internal  derangement  of 
the  knee-joint,  Bennett  found  that  the  internal 
cartilage  was  affected  in  155  cases  and  the  external 
in  only  45.  The  left  knee  was  the  seat  of  derange- 
ment nearly  three  times  as  often  as  the  right,  and 
the  lesion  occurred  nine  times  more  frequently  in 
men  than  in  women.  In  every  one  of  twelve  cases 
operated  on  by  Marsh,  the  anterior  extremity  of 
the  internal  semilunar  cartilage  was  found 
bruised  and  torn  from  its  tibial  attachment.  To 
understand  the  liability  to  injury  of  the  anterior 
part  of  the  internal  semilunar  cartilage  it  is 
necessary  to  examine  the  manner  in  which  it  is 
maintained  in  position,  the  movements  which  it 
undergoes,  and  the  strains  to  which  it  is  sub- 
jected in  active  athletes — for  it  is  amongst  them 
that  displacements  most  frequently  occur.  In  the 
extended  position  of  the  knee,  displacement  is 
impossible,  for  the  cartilages  are  immovably 
fixed  by  the  coaptation  of  the  articular  surfaces, 
brought  about  by  the  tension  of  the  ligaments  and 
tonus  of  the  muscles  surrounding  the  joint.  When 
the  joint  is  partly  flexed  the  internal  cartilage  is 
fixed  by  (1)  its  anterior  horn  attached  to  the  tibia, 
above  and  behind  the  attachment  of  the  liga- 
mentum  patellae  and  outside  the  joint  cavity  (Fig. 
87) ;  (2)  by  the  transverse  ligament  to  the  anterior 
part  of  the  external  cartilage  (Fig.  87) ;  (3)  by 
the  coronary  ligament  to  the  capsule  of  the  joint 
and  internal  lateral  ligament;  the  anterior  fibres 
of  this  ligament  are  the  longest  (Fig.  87).  As  the 
joint  is  flexed  the  cartilages,  especially  the  in- 
ternal, glide  backwards;  if  in  this  position  the 
biceps  brings  about  a  sudden  rotation  outwards 
of  the  tibia,  the  anterior  horn  is  carried  forwards 


Chap.  XXI]       REGION   OF   THE    KNEE  539 

and  outwards  with  that  bone,  while  the  posterior 
is  firmly  fixed  to  the  internal  condyle  of  the 
femur  by  the  internal  lateral  ligament,  and  thus 
a  severe  strain  is  thrown  on  the  anterior  part 
of  the  internal  cartilage,  which  is  brought  into 
the  position  shown  in  Fig.  87.  Its  weakest  point 
is  in  the  thin  inner  crescentic  margin  of  its  an- 
terior third,  and  it  is  here  that  partial  rupture 
usually  occurs.  The  intense  pain  is  due  to  the 
rupture  and  to  the  fact  that  the  strain  wedges 
the  cartilage  between  the  tibia  and  femur,  thus 
forcing  them  apart  and  causing  an  instant  and 
severe  hyperextension  of  the  unyielding  liga- 
ments of  the  joint.  The  external  cartilage  is 
smaller  than  the  internal,  is  rounder,  is  more 
movable,  and  possibly  on  these  accounts  is  less 
likely  to  be  "  nipped  ,;  between  the  bones.  It  is 
attached  in  part  to  the  femur  through  the  pos- 
terior crucial  ligament,  and  is  grooved  by  the 
tendon  of  the  popliteus,  two  factors  which  add 
to  its  security  (Fig.  87). 

4>c ii ii- valgum,  or  knock-knee.  —  The  appear- 
ances produced  by  this  affection  are  familiar. 
When  a  person  stands  erect  with  the  feet  together, 
the  tibiae  are  practically  vertical,  and  the  femora 
meet  them  at  a  certain  angle.  The  degree  of  this 
angle  depends,  in  normal  subjects,  to  a  great 
extent  upon  the  relative  width  of  the  pelvis.  In 
genu-valgum  the  tibiae  cease  to  be  vertical  in  the 
erect  position ;  their  lower  ends  deviate  more  and 
more  from  the  middle  line,  until  the  distance  be- 
tween the  two  malleoli  becomes  considerable  when 
the  individual  stands  upright  and  when  he  is 
not  concealing  any  of  the  deformity  by  rotating 
the  limb. 

The  progress  of  the  genu-valgum  may  be  di- 
vided into  three  stages.  In  the  first  stage  there 
is  a  yielding  or  elongation  of  the  internal  lateral 
ligament,  and  of  the  fascial  structures  on  the 
inner  side  of  the  joint.  That  the  yielding  of  this 
ligament  alone  will  permit  of  a  lateral  movement 
at   the    articulation   being   accomplished    is   illus- 


540 


SURGICAL    APPLIED    ANATOMY      [Part  V 


trated  by  cases  of  sprains  of  the  knee,  where  the 
ligament  has  been  torn,  and  where  much  lateral 
bending  has  been  in  consequence  permitted.  It 
is  probable  that  the  crucial  ligaments  yield  also 
a  little,  and  it  is  upon  the  posterior  band  at- 
tached to  the  internal  condyle  that  the  strain 
possibly  first  comes.  In  the  second  stage  there 
is  a  contraction  of  the  tissues  on  the  outer  side  of 
the  joint  that  have  been  relaxed  by  the  new  posi- 
tion of  the  limb.  These  structures  are  the  ilio- 
tibial  band  of  the  fascia  lata,  the  external  lateral 
ligament,    and   the  biceps  tendon.     This  contrac- 


Fig.  88. — a,  Normal  femur  ;  b,  femur  in  an  advanced  state  of  knock-knee, 
showing  the  enlargement  of  the  internal  condyle.  The  dotted  line  in 
each  case  represents  the  line  of  the  epiphysis. 

tion  tends  to  give  permanency  to  the  deformity. 
In  the  third  stage  the  bones  become  changed. 
On  the  outer  side  of  the  joint  the  external  con- 
dyle and  the  outer  tuberosity  of  the  tibia  are 
pressed  together,  and  through  these  bones  the 
greater  part  of  the  weight  of  the  body  will  be 
transmitted.  As  a  result  of  the  continual  pres- 
sure the  parts  waste  a  little,  and  by  their  atrophy 
contribute  not  only  to  the  extent  of  the  deformity 
but  also  to  its  permanency.  On  the  inner  side 
the  internal  condyle  tends  to  become  separated 
from  the  tibia,  and  an  interval  to  develop  be- 
tween the  two  bones  as  the  deformity  advances. 
This  interval  is  prevented  from  actually  existing 


Chap.  XXI]       REGION   OF   THE    KNEE. 


541 


«&-«$ 


by  the  development  of  the  condyle,  which  enlarges, 
and  so  still  maintains  its  contact  with  the  tibia. 
Mikulicz  has  pointed  out  that  "  the  alteration 
in  length  on  the  inner  side  of  the  femur  arises  not 
from  alteration  of  the  epiphysis,  but  is  confined 
to  the  lowest  part  of  the  diaphysis."  This  state- 
ment also  holds  true  for  the  tibia.  This  is  shown 
in  the  diagram  (Fig.  88),  where  it  will  be  seen 
that  the  enlargement  of  the  internal  condyle  is 
due  almost  entirely  to  increased  growth  in  the 
diaphysis.  The  increased  growth  does  not  affect 
the  antero-posterior  diameter  of  the  condyles. 
Hence,  when  the  knee  is  flexed,  all  trace  of  the 
deformity  disappears. 

The  patella.— Fractures.  This  bone  is  more 
often  broken  by  muscular  violence  than  is  any 
other  in  the  body.  Although  the  patella  may 
be  fractured  by  both  mus- 
cular and  direct  violence, 
it  would  appear  that  the 
former  is  the  agent  that 
most  often  produces  the 
lesion.  Thus,  in  127  cases 
of  simple  transverse  frac- 
ture collected  by  Hamilton, 
he  considers  that  muscular 
action  was  the  cause  of  the 
injury  in  106  instances.    The    Fi?    S9._Diagram  "to   show 

IOrm      Or      fracture      due      to         mechanism    of   fracture    of 

muscular  violence  is  very  *•"»  patella  by  muscular 
uniform.      It    is    nearly    al- 

■  •  i  a,  Line  of  action  of  ciuadriL'eps 

w ay s      tr an s ve rs e ,      simp le ,      muscle ;  &,  femur ;  c,  tibia. 
and  through ^  the   centre   of 

the  bone,  or  just  above  that  point  or  just  below  it. 
Fractures  due  to  direct  violence  may  present  the 
same  appearance,  but  they  are  more  often  starred, 
or  oblique,  or  even  longitudinal.  Experiments  upon 
the  cadaver  show  that  a  simple  transverse  frac- 
ture about  the  centre  of  the  bone  cannot  be  pro- 
duced with  any  degree  of  certainty  by  a  direct 
blow.  The  position  of  the  knee  that  most  favours 
fracture   by   muscular   action   is   that  of   flexion. 


542  SURGICAL    APPLIED    ANATOMY      [Part  V 

When  the  knee  is  bent,  the  patella  rests  upon  the 
femoral  condyles  along  its  transverse  axis  only. 
Nearly  the  whole  of  its  upper  half  is  unsupported 
behind,  and  the  extensor  muscle  acts  in  a  line 
nearly  at  right  angles  to  the  vertical  axis  of  the 
bone.  Thus,  by  violent  contraction  of  the  quadri- 
ceps, the  patella  may  be  snapped  across  the  con- 
dyle as  a  stick  is  snapped  across  the  knee  (Fig.  89). 
As  the  fracture  usually  causes  the  patient  to  fall, 
it  has  been  supposed  that  the  contact  with  the 
ground,  rather  than  any  previous  muscular 
action,  may  have  caused  the  lesion.  But,  as 
Hamilton  has  pointed  out,  if  a  person  falls  upon 
the  bent  knee  when  the  limb  also  is  flexed  upon 
the  trunk,  the  part  that  comes  in  contact  with 
the  ground  is  not  the  patella,  but  the  tubercle 
of  the  tibia. 

In  the  great  majority  of  cases  the  lesion  not 
only  involves  the  bone  but  also  the  cartilage  and 
fibrous  structures  that  cover  it  respectively  be- 
hind and  in  front;  the  synovial  membrane  also 
is  torn,  and  the  patella  bursa  opened  up.  Thus 
the  synovial  contents  may  come  in  actual  contact 
with  the  skin.  "  It  is  anatomically  possible,  if 
the  fracture  involve  only  the  lower  and  non- 
articular  portion  of  the  patella,  and  if  the  amount 
of  the  separation  of  fragments  is  slight,  that  the 
fatty  tissue  behind  the  apex  of  the  patella,  over 
which  the  synovial  membrane  is  reflected,  may 
save  the  latter  from  injury "  (Henry  Morris). 
In  all  cases  where  there  is  much  separation  of  the 
fragments,  the  fibrous  expansion  attached  to 
either  side  of  the  patella  must  be  torn  through. 
Indeed,  none  but  a  slight  separation  of  the  parts 
is  possible  until  tnat  expansion  is  ruptured. 
Braune  has  demonstrated  this  by  experiment,  by 
sawing  through  the  patella  without  damage  to 
the  lateral  ligamentous  structures,  and  noting 
that  but  trifling  separation  of  the  fragments  was 
possible  until  these  structures  had  been  divided. 
In  stellate  fractures,  due  to  direct  violence,  these 
fibrous  expansions  from  the  extensor  tendon  may 


Chap.  XXI]        REGION    OF   THE    KNEE 


543 


a 


be  uninjured,  and  no  separation  of  any  magni- 
tude be  permitted  between  the  portions  of  the 
broken  bone. 

The  patella  is  more  readily  broken  by  muscular 
violence  than  is  either  the  extensor  tendon  or  the 
ligamentum  patellae.  In  the  flexed  position  it 
will  be  seen  (Fig.  89)  that  the  bone  is  placed 
at  a  considerable  disadvantage  when  compared 
with  the  two  other  structures.  Richet  reports  a 
case  where  violent  contraction  of  the  quadriceps 
caused  the  tubercle  of  the  tibia  to  be  torn  away 
from  the  bone  without  any  other  lesion  of  the 
parts  immediatelv  concerned  being  produced. 

The  patella  may  be  congenitally  absent.  It  is 
developed  in  the  tendon  of  the  quadriceps,  re- 
maining cartilaginous  until  the  end  of  the  second 
year.  Its  sesa- 
moid nature  is 
seen  in  the  ten- 
dency to  unite  by 
fibrous  rather 

than  by  bony 
union  after  frac- 
ture. It  receives 
its  blood  supply 
from  nearly  all 
the  art'eries 
round  the  knee- 
joint. 

Dislocation 
of  the  patella, 
— This  bone  may 
be  dislocated  out- 
wards or  in- 
wards, or  turned 
upon  its  edge  so 
that  its  interior 
and  posterior 
surfaces  are 
placed  laterally. 
The  luxation  out- 
wards  is    by    far 


Fig.  90.— Transverse  section  of  left  knee- 
joint  through  the  centre  of  the  patella. 
(Braune.y 

a,  Bursa  patellae;  &,  internal  lateral  ligament  and 
inner  condyle;  c,  external  lateral  ligament 
and  outer  condyle  -}  d,  biceps:  e,  semimem- 
branosus ;  /.  spmitendinosus ;  f/,  gracilis 
tendon  ;  h,  sartorius.  1,  internal  popliteal 
nerve;  2,  external  popliteal  nerve;  3,  inter- 
nal saphenous  vein.^ 


544  SURGICAL   APPLIED    ANATOMY      [Part  V 

the  most  common.  This  depends  upon  the 
fact  that  the  quadriceps,  the  patella,  and 
the  ligamentum  patellae  do  not,  when  the 
muscle  is  contracted,  follow  the  lines  of  the  femur 
and  tibia.  They  are  more  nearly  in  a  straight 
line,  that  passes  to  the  outer  side  of  the  angle 
formed  by  the  femur  with  the  leg  at  the  knee- 
joint.  Muscular  contraction,  therefore,  tends  to 
draw  the  knee-cap  outwards,  a  tendency  that^  is 
in  all  normal  circumstances  corrected  by  the  in- 
creased prominence  of  the  external  condyle.  The 
vastus  externus  also  is  said  to  be  more  powerful 
than  the  internus.  The  tensor  vaginae  femoris  has 
an  attachment  to  the  patella  through  the  ilio- 
tibial  band.  Bv  the  sudden  action  of  this  muscle 
a  patient  of  Mr.  Rigby  was  able  to  produce  a 
voluntary  outward  dislocation  of  the  patella. 
Dislocations  usually  occur^in  the  extended  posi- 
tion of  the  joint,  and  are  commonly  due  to  mus- 
cular action. 

In  the  dislocation  of  the  patella  upon  its  edge, 
the  inner  border  of  the  bone  usually  projects 
forwards,  while  the  outer  is  placed  between  the 
condyles.  But  little  is  known  as  to  the  mechanism 
of  this  dislocation. 

In  dislocations  of  the  knees  which  are  very 
rare,  the  tibia  may  be  displaced  outwards,  in- 
wards, forwards,  or  backwards.  The  two  lateral 
luxations  appear  to  be  more  common  than  the 
antero-posterior.  The  former  are  nearly  always 
partial,  the  latter  usually  complete.  Consider- 
able violence  is  required  to  produce  these  luxa- 
tions, owing  to  the  great  strength  of  the  liga- 
ments and  muscles  and  the  great  width  of  the 
bones  involved.  Direct  violence  to  the  tibia  or 
femur,  associated  often  with  a  twisting  of  the 
former  bone,  is  the  common  cause  of  the  lesion. 
It  is  probable  that  in  all  luxations  of  the  knee 
the  crucial  ligaments  are  torn.  The  lateral  liga- 
ments also  are  usually  ruptured,  but  in  the 
partial  luxations  they  may  be  sometimes  found  to 
be  intact.     The  tendinous  expansion  of  the  vasti 


Chap.  XXI]       REGION   OF   THE    KNEE  545 

in  front  of  the  knee  seldom  escapes  some  lacera- 
tion, even  in  the  partial  dislocations.  The  pro- 
jection of  the  spine  of  the  tibia  between  the  femoral 
condyles  offers  an  obstruction  to  lateral  luxation. 
Dr.  F.  S.  Mackenzie  found  by  experiment  on  the 
dead  body  that  division  of  the  crucial  ligaments 
did  not  materially  influence  the  force  necessary  to 
produce  a  dislocation  at  the  knee-joint.  He 
found,  too,  that  in  seven  out  of  eight  experiments, 
dislocation  was  produced  and  not  fracture— 
whereas  in  life  fracture  is  by  far  the  commoner 
result.  He  concludes,  therefore,  that  the  strength 
of  the  joint  depends  on  the  surrounding  muscles 
rather  than  on  the  surrounding  ligaments.  The 
popliteal  vessels  and  nerves  are  much  compressed, 
and  appear  to  be  more  severely  injured  by  the 
femur  in  the  forward  dislocation  than  by  the 
tibia  in  the  backward  displacement. 

The  lower  end  of  the  femur. — The  condylar 
part  of  the  femur  _is  composed  almost  wholly  of 
cancellous  bone,  with  but  a  slight  layer  of  com- 
pact tissue.  It  is  so  spongy  that  it  may  be 
pierced  by  a  bullet,  as  pointed  out  by  Legouest, 
without  any  splintering  of  the  bone  being  pro- 
duced and  without  damage  to  the  articulation. 
The  fractures  that  may  be  met  with  in  the  lower 
end  of  the  bone  are  the  following  :  (l)  a  fracture 
of  the  shaft  above  the  condyles;  (2)  a  separation 
of  the  lower  epiphysis;  (3)  a  fracture  separating 
either  the  outer  or  inner  condvle ;  (4)  a  T-shaped 
fracture,  i.e.  a  transverse  fracture  above  the  con- 
dyles with  a  vertical  one  between  those  processes. 
These  lesions  are,  as  a  rule,  due  to  well  localised 
direct  violence.  Fractures  Nos.  1  and  4  may  be 
produced  by  indirect  violence,  as  by  a  fall  upon 
the  feet  from  a  height.  Henry  Morris  states  that 
lateral  flexion,  or  force  applied  in  a  lateral  direc- 
tion, is  best  calculated  to  produce  a  separation 
of  the  epiphysis.  Hamilton  reports  a  strange  case 
in  a  man  aged  21,  whose  outer  condyle  was  frac- 
tured by  a  twist  of  the  leg,  which  happened 
while  he  was  undressing  himself  to  bathe.  The 
2  J 


546  SURGICAL    APPLIED    ANATOMY      [Part  V 

only  fracture  that  requires  special  notice  in  this 
place  is  the  fracture  of  the  shaft  just  above  the 
condyles.  The  lesion  is  situated  generally  about 
2  inches  above  the  line  of  the  epiphysis,  and  corre- 
sponds to  the  spot  where  the  compact  shaft  joins 
the  softer  and  more  cancellous  tissue  of  the  lower 
end  of  the  bone.  It  is  near  the  place,  also,  where 
the  femoral  artery  crosses  the  bone  to  reach  the 
ham,  and  it  has  thus  happened  that  the  vessel 
has  been  wounded  by  splinters  in  this  particular 
injury.  The  fracture  is  usually  oblique,  from  be- 
hind downwards  and  forwards.  The  lower  frag- 
ment will  be  drawn  upwards  by  the  same  muscles 
that  produce  shortening  in  other  fractures  of  the 
shaft  (p.  518),  and  its  sharp  upper  end  is  very 
apt  to  be  pulled  forcibly  into  the  popliteal  space 
by  the  gastrocnemius  muscle.  This  latter  displace- 
ment is  difficult  to  remedy.  If  the  limb  be  ex- 
tended, the  fragment  is  only  drawn  the  more  into 
the  ham,  and  it  is  therefore  possible  for  the  limb 
to  appear  straight  and  yet  have  the  knee-joint 
much  bent.  In  several  cases  of  this  injury  I 
divided  the  tendo  Achillis,  and  then  placed  the 
limb  upon  a  straight  splint,  following  a  practice 
suggested  by  Mr.  Bryant.  The  effect  upon  the 
position  of  the  fragments  was  in  each  case  very 
good  (Brit.  Med.  Jour.,  1883).  The  lower  frag- 
ment of  the  femur  may  be  replaced  by  completely 
flexing  the  leg  on  the  thigh.  (Hutchinson  and 
Barnard.) 

The  upper  end  of  the  tibia  is  sometimes 
the  seat  of  fracture,  although  of  all  parts  of  this 
bone  the  upper  third  is  the  part  least  often 
broken.  One  or  other  of  the  tuberosities  may  be 
broken  off,  or  there  may  be  a  transverse  or  oblique 
fracture  of  the  upper  end  of  the  shaft  associated 
with  a  vertical  one  running  up  into  the  joint  be- 
tween the  two  tuberosities.  Such  accidents  are  the 
result,  in  nearly  every  instance,  of  great  direct 
violence.  Madame  Lachapelle  reports  a  case  of 
separation  of  the  upper  epiphysis  of  the  tibia 
caused  by  traction  during  parturition;  but  I  am 


Chap.  XXI]       REGION    OF    THE    KNEE 


547 


not  aware  of  any  reported  case  of  separation  of 
this  epiphysis  due  to  violence  or  under  circum- 
stances other  than  this.  Mr.  Makins  reports 
three  cases  of  separation  of  the  anterior  tuber- 
osity in  adolescents.  It  is  usually  ossified  by  an 
extension  from  the  epiphyseal  centre  for  the  upper 
extremity  of  the  tibia,  but  may  have  a  separate 
centre   (Schlatter). 

The  spongy  tissue  in  the  head  of  this  bone  and 
in  the  lower  end  of  the  femur  is,  par  excellence, 
the  favourite  seat  for  myeloid  sarcomata. 

In  excising  the  knee-joint  through  an  in- 
cision commencing  at  the  back  of  one  condyle,  and 
continued  across  the  joint,  just  below  the  patella, 
to  the  back  of  the  other  condyle,  the  following 
structures  are  divided  :  Skin,  fascia,  patellar 
plexus  of  nerves  (formed  by  the  middle  and  in- 
ternal cutaneous  and  the  patellar  branch  of  the 
long  saphenous),  bur- 
sa patellse,  anterior 
part  of  the  capsule, 
ligamentum  patellae, 
synovial  membrane, 
lateral  and  crucial 
ligaments,  the  supe- 
rior and  inferior  arti- 
cular arteries,  the 
anastomotica  magna, 
and  the  anterior  ti- 
bial recurrent  ves- 
sels. 

The  incision  over 
the  inner  condyle 
need  not  be  made  so 
far  back  as  to  divide 
the  internal  saphen- 
ous vein  and  nerve. 
In  sawing  the  femur 
it  is  most  important 
that  the  exact  incli- 
nation of  the  joint 
surface   of  the    bone 


q    p  m      I 

Fig.  91.— Disarticulation  at  the  knee- 
joint  by  single  anterior  flap.    (Agate.) 

a,  Int.  condyle;  ft,  ext.  condyle;  c,  inter- 
condyloid  fossa ;  d,  lig.  patella? :  e,  sar- 
torius  ;  /;  gracilis  ;  g,  semitendinosus  ; 
li,  ext.  lat.  ligament;  i,  popliteus  ;  j, 
plantaris  ;  k,  semimembranosus  ;  I  and 
m,  inner  head  of  gastrocnemius :  n,  outer 
head  of  gastrocnemius;  o,  biceps;  p, 
popliteal  vessels  ;  q,  int.  pop.  nerve. 


548  SURGICAL    APPLIED    ANATOMY      [Part  V 

be  reproduced.  If  improperly  sawn  the  patient 
would  be  bow-legged  or  knock-kneed.  The  rule, 
therefore,  is  that  the  saw  be  applied  parallel  to 
the  articular  surface  and  perpendicular  to  the 
shaft. 

In  young  subjects  care  must  be  taken  that  the 
saw-cuts  do  not  pass  beyond  the  epiphyseal  line. 
The  upper  limit  of  the  femoral  epiphysis  will  be 
represented  by  a  horizontal  line  drawn  across  the 
bone  at  the  level  of  the  tubercle  for  the  adductor 
magnus.  If  the  whole  of  the  trochlear  surface 
be  removed  in  the  excision  the  whole  of  the  epi- 
physis will  have  been  taken  away.  A  single 
nucleus  appears  in  this  epiphysis  shortly  before 
birth,  and  joins  the  -snaft  about  the  twentieth 
year.  The  limits  to  the  tibial  epiphysis  are  repre- 
sented behind  and  at  the  sides  by  a  horizontal  line 
that  just  marks  off  the  tuberosities.  It  includes, 
therefore,  the  depression  for  the  insertion  of  the 
semimembranosus,  and  also  the  facet  for  the  fibula. 
In  front  the  epiphyseal  line  slopes  downwards  on 
either  side  to  a  point  on  the  upper  end  of  the 
shin,  so  as  to  enclose  the  whole  of  the  tubercle 
of  the  tibia.  The  centre  joins  the  main  bone  at 
the  twenty-first  or  twenty-second  year.  The  popli- 
teal artery  runs  some  risk  of  being  wounded  in 
excision  of  the  joint.  The  vessel  is  separated  by 
some  little  distance  from  the  popliteal  surface  of 
the  femur  (Fig.  91),  but  is  in  very  close  relation 
to  the  tibia,  the  posterior  ligament  alone  inter- 
vening at  the  upper  level  of  the  bone.  It  thus 
happens  that  the  risk  of  wounding  the  artery  is 
greater  when  the  tibia  is  sawn  than  when  the 
lower  part  of  the  femur  is  being  removed. 

Excision  of  the  knee  is,  to  a  large  extent,  re- 
placed by  arthrectomy.  Indeed,  excision  of  this 
joint  carried  out  in -the  complete  manner  just  de- 
scribed must  be  classed  as  quite  a  rare  operation. 

Amputation  through  the  knee-joint,,— To 
illustrate  the  anatomy  of  the  part  an  amputation 
by  a  single  anterior  flap  may  be  selected  (Fig. 
91).      In  fashioning  the  anterior  flap    (composed 


Chap.  XXI]       REGION   OF   THE    KNEE  549 

only  of  integument),  and  in  opening  the  joint, 
the  patellar  plexus  of  nerves,  the  superficial 
branches  of  the  plexus  of  arteries,  the  ligamentum 
patellae,  and  the  anterior  part  of  the  capsule  will 
be  cut.  Nearer  the  condyles  of  the  femur  the 
anastomotic  and  the  two  superior  articular 
arteries  will  be  divided.  The  long  saphenous  vein 
and  nerve  will  be  divided  at  the  inner  angle  of 
the  flap.  On  the  cut  surface  made  by  the  posterior 
incision  will  be  found  divided  the  sartorius, 
gracilis,  and  semitendinosus,.  the  semimembran- 
osus, both  heads  of  the  gastrocnemius,  the  popli- 
teus,  plantaris,  and  biceps.  The  popliteal  vessels, 
the  sural  arteries,  the  short  saphenous  vein,,  the 
internal  and  external  popliteal  nerves,  the  ex- 
ternal saphenous  and  the  small  sciatic  nerves  will 
also  be  found  divided  in  the  same  incision. 

The  most  convenient  amputation  at  the  knee- 
joint  is  by  equal  lateral  flaps  (Stephen  Smith's 
operation).  This  operation  has  been  attended  by 
excellent  results,  and  in  actual  practice  the 
method  of  amputation  by  a  single  anterior  flap 
is  but  very  rarely  employed. 


CHAPTER    XXII 

THE    LEG 

Surface  anatomy. — The, anterior  border  of  the 
tibia  can  be  felt  in  its  entire  length,  forming, 
as  it  does,  the  prominence  of  the  shin.  It  should 
be  remembered  that  this  border  presents  a  some- 
what flexuous  course,  being  curved  outwards  above 
and  inwards  below.  The  broad  internal  surface 
of  the  bone  is  subcutaneous,  and  the  internal 
border  can  be  followed  from  the  tuberosity  to  the 
malleolus.  The  head  of  the  fibula  can  be  dis- 
tinctly made  out,  but  the  upper  half  of  the  shaft 
of  the  bone  is  lost  beneath  the  mass  of  muscle  on 
the  outer  side  of  the  limb.  The  lower  half  of  the 
fibular  shaft  can  be  felt,  and  the  bone  just  above 
the  malleolus  becomes  subcutaneous  in  the  interval 
between  the  peroneus  tertius  and  the  two  other 
peroneal  tendons.  The  fibula  is  situated  so  far 
behind  the  line  of  the  tibia  that  a  knife  thrust 
transversely  through  the  leg  from  the  inner  side 
behind  the  tibia  will  appear  in  front  of  the  fibula 
on  the  outer  side  (Fig.  93).  Between  the  tibia  and 
fibula  the  outline  of  the  tibialis  anticus  muscle 
can  be  well  defined  when  it  is  in  action.  To  its 
outer  side  is  the  less  conspicuous  and  narrower 
eminence  formed  by  the  extensor  communis  digi- 
torum.  In  well-developed  limbs  the  groove  that 
separates  these  two  muscles  is  very  distinct,  and 
forms  the  best  guide  to  the  anterior  tibial  artery. 
In  the  lower  third  of  the  leg  these  muscles  be- 
come  tendinous,    and   between   them   the   extensor 

550 


Chap.  XXII]  THE    LEG  551 

longus  hallucis  can  be  felt  as  it  comes  to  the  sur- 
face. The  long  and  short  peroneal  muscles  can  be 
defined,  and  their  tendons  followed  behind  the 
malleolus.  When  in  active  contraction  the  in- 
terval between  the  two  muscles  is  often  well 
marked.  The  gastrocnemius  muscle  and  the  more 
superficial  parts  of  the  soleus  are  brought  well 
into  view  when  the  body  is  raised  upon  the  toes. 
The  two  heads  of  the  former  muscle  are  then  quite 
conspicuous,  and  it  can  be  seen  that  the  inner  head 
is  the  larger  and  descends  lower  in  the  leg. 

The  popliteal  artery  bifurcates  on  a  level  with 
the  lower  part  of  the  tubercle  of  the  tibia.  The 
course  of  the  posterior  tibial  vessel  is  represented 
by  a  line  drawn  from  the  middle  of  the  limb  at 
the  lower  part  of  the  ham  to  a  spot  midway  be- 
tween the  inner  malleolus  and  the  prominence  of 
the  heel.  The  artery  becomes  superficial  in  the 
lower  fourth  of  the  leg,  where  it  may  be  felt 
pulsating  between  the  tendo  Achillis  and  the  tibia. 
The  peroneal  artery  arises  about  3  inches  below 
the  knee,  follows  the  posterior  surface  of  the 
fibula,  and  ends  behind  the  outer  malleolus.  The 
position  of  the  anterior  tibial  artery  may  be  in- 
dicated by  a  line  drawn  from  a  point  midway 
between  the  outer  tuberosity  of  the  tibia  and  the 
head  of  the  fibula  to  the  centre  of  the  front  of  the 
ankle-joint.  Both  the  saphenous  veins  can  often 
be  made  out  in  the  leg.  The  inner  or  larger  vein 
passes  in  front  of  the  malleolus  and  ascends  just 
behind  the  internal  border  of  the  tibia.  With  it 
runs  the  long  saphenous  nerve.  The  short  saphen- 
ous vein  lies  behind  the  outer  malleolus,  and  pass- 
ing up  the  middle  of  the  calf  ends  at  the  ham.  It 
is  accompanied  by  the  external  saphenous  nerve. 

The  legr. — The  shin  is  somewhat  more  adherent 
to  deeper  parts  in  the  leg  than  it  is  in  the  thigh. 
The  difference  in  the  degree  of  this  adhesion  is 
obvious  when  skin-flaps  are  dissected  up  from  the 
two  parts  in  cases  of  amputation.  Over  the  in- 
ternal surface  of  the  tibia  and  the  greater  part  of 
the   shin,    the   integument  lies   directly   upon   the 


552  SUKGICAL   APPLIED   ANATOMY      [Part  V 

periosteum  and  bone,  nothing  intervening  save  a 
scanty  amount  of  subcutaneous  fascia.  Thus  blows 
and  kicks  over  these  parts  of  the  leg  are  apt  to  be 
associated  not  only  with  much  pain  but  also  with 
much  bruising  or  tearing  of  the  integument.  A 
"  graze  on  the  shin  "  is  one  of  the  commonest  of 
lesions,  and  is  produced  by  a  degree  of  violence 
that  upon  a  well-covered  part  would  have  little 
or  no  effect.  It  will  be  understood  that  ulcers  over 
these  feebly  protected  parts  may,  if  they  spread 
in  depth,  readily  expose  the  bone  and  lead  to  some 
disease  of  its  substance,  or  to  at  least  some  inflam- 
mation of  its  periosteum.  (Scars  left  by  deep 
ulcers  or  burns  are  also  often  found  to  be  quite 
adherent  to  the  bone. 

The  aponeurosis  of  the  leg  invests  it  like  a 
tightly-drawn  buskin,  being  lacking  only  over  the 
subcutaneous  surfaces  of  the  bones.  It  is  attached 
to  the  head  and  the  anterior  and  inner  borders  of 
the  tibia,  the  head  of  the  fibula,  and  the  two 
malleoli.  It  is  continuous  above  with  the  fascia 
lata,  and  below  with  the  fascia  of  the  foot  and  the 
annular  ligaments.  It  is  thicker  in  front  than 
behind,  and  is  especially  thick  at  the  upper  part 
of  the  leg  just  below  the  knee.  Here  the  fascia 
offers  great  resistance  to  the  growth  of  tumours 
springing  from  the  head  of  the  tibia.  From  the 
deep  surface  of  the  aponeurosis  two  septa  pass 
inwards  to  be  attached  to  the  anterior  and  ex- 
ternal borders  of  the  fibula.  They  serve  to  isolate 
the  two  larger  peroneal  muscles  from  the  other 
muscles  of  the  limb,  and  form  a  closed  space  which 
might  become  a  definite  and  well  localised  cavity 
for  pus.  Beneath  the  gastrocnemius  and  soleus  a 
layer  of  fascia  extends  between  the  two  bones  and 
covers  in  the  deep  layer  of  muscles.  It  is  thin 
above  but  denser  below,  and  would  have  some  in- 
fluence in  directing  the  progress  of  a  deep  abscess. 
In  the  upper  third  of  the  leg  there  is  a  septum 
between  the  tibialis  anticus  and  extensor  com- 
munis digitorum,  which  must  be  found  in  the 
operation    for    ligaturing   the   upper    part  of  the 


Chap.  XXII]  THE    LEG  553 

anterior  tibial  artery.  I  have  never  had  the  good 
fortune  to  see  the  very  distinct  "  white  line  }>  that 
many  text-books  describe  as  indicating  the  posi- 
tion of  this  septum. 

In  the  substance  of  the  soleus  muscle  there  is  a 
tendinous  expansion  connected  with  the  border  of 
the  tibia,  that  runs  backwards  and  towards  the 
middle  line.  In  cutting  through  the  soleus  to 
apply  a  ligature  to  the  posterior  tibial  artery, 
this  intersection  may  be  mistaken  for  the  aponeu- 
rosis on  the  deep  surface  of  the  muscle. 

Several  cases  are  reported  of  rupture  of  some 
part  of  the  gastrocnemius  muscle  during  violent 
exertion.  The  tendo  Achillis  has  been  ruptured 
under  like  circumstances.  It  is  said  that  the  plan- 
taris  tendon  is  also  not  unfrequently  torn  across, 
producing  a  sudden  sharp  pain  in  the  calf  during 
exertion,  to  which  the  French  give  the  name 
"  coup  de  fonet." 

Vessels. — The  large  arteries  of  the  leg,  being 
all  in  close  proximity  with  the  bones,  are  apt  to 
be  injured  by  sharp  fragments  in  fractures  of  the 
limb.  This  especially  applies  to  the  peroneal 
artery,  which  runs  along  the  fibula  in  a  fibrous 
canal,  and  is  in  considerable  risk  of  being 
wounded  in  fractures  about  the  middle  of  that 
bone.  It  is  at  the  point  of  bifurcation  of  the 
popliteal  artery  that  emboli  are  peculiarly  apt  to 
lodge.  They  plug  the  vessel  and  practically  block 
the  three  main  arteries  of  the  leg.  Gangrene, 
therefore,  not  unfrequently  follows  the  occurrence. 
Billroth  states  that  in  all  the  cases  of  gangrene  of 
the  leg  due  to  embolism  that  he  has  met  with,  the 
plug  was  found  situated  at  the  bifurcation  of  the 
popliteal  trunk  ("  Clinical  Surgery,"  1881).  Ac- 
cording to  some  French  surgeons,  aneurism  of  the 
commencement  of  the  posterior  tibial  artery  is 
more  often  associated  with  gangrene  of  the  leg 
than  is  a  popliteal  aneurism.  The  reason  they 
assign  is  the  following  :  The  aneurism  on  the 
former  vessel  not  only  interferes  with  the  passage 
of  the  blood  into  the  posterior  tibial  and  peroneal 


554  SURGICAL    APPLIED    ANATOMY      [fart  V 

arteries,  but  also  compresses  the  anterior  tibial 
vessel  and  with  it  the  anterior  tibial  recurrent,  an 
artery  that  is  of  so  great  importance  in  establish- 
ing the  collateral  circulation. 

Varicose  veins  are  more  commonly  met  with 
in  the  leg  than  in  any  other  part  of  the  body,  save, 
perhaps,  in  the  hemorrhoidal  and  spermatic 
veins.  This  depends  upon  the  great  length  of  the 
veins  of  the  lower  limb,  the  large  columns  of  blood 
their  valves  have  to  support,  their  vertical  posi- 
tion, the  liability  of  the  great  trunks  (iliac),  into 
which  they  ultimately  enter,  to  be  compressed, 
and  upon  the  fact  that  the  superficial 
veins,  being  outside  the  fascia,  lose  that 
assistance  to  the  circulation  derived 
from  muscular  contraction.  From  a 
/  '  \  physical    point    of    view    the    vascular 

(         * c   system  must  be  regarded  as  a  vertical 

\      J~       '   column   of   fluid.     The  lower  the  level 
1 1  the  greater  is  the  pressure  on  the  con- 

I  taining  walls.    The  saphenous  veins  are 

^  thin-walled,    distensible  tubes  situated 

Fig.  92.  outside  the  rigid-walled  cylinder 
formed  by  the  deep  fascia  of  the  leg 
and  thigh,  low  in  the  body,  where  the  pressure 
from  gravity  is  greatest  (Hill).  The  use  of 
garters  especially  affects  the  long  saphenous  vein, 
which  lies  close  to  the  bone  at  the  spot  about 
which  these  contracting  bands  are  usually  applied. 
Between  the  two  layers  of  the  muscles  of  the  calf 
Verneuil  describes  a  venous  plexus,  which  he  be- 
lieves to  be  more  often  the  seat  of  varices  than  are 
the  vessels  of  the  surface.  A  varicose  condition  of 
these  deeply  placed  veins  may  explain  the  "  aching 
legs  ;;  complained  of  by  those  who  stand  a  great 
deal.  The  intramuscular  veins  are  very  large. 
Callender  showed  that  the  six  chief  veins  which 
pass  from  the  soleus  muscle  alone  to  enter  into 
the  posterior  tibial  and  peroneal  trunks  have  a 
united  diameter  of  not  less  than  1  inch.  Varix 
would  appear  to  commence  most  often  at  points 
where  the  deep  veins  join  the  superficial  vessels. 


Chap.  XXII]  THE    LEG  555 

There  is  good  reason  for  this,  for  at  these  points 
three  forces  meet,  the  general  directions  of  which 
are  shown  in  the  annexed  diagram  (Fig.  92). 
There  is  the  weight  of  the  superincumbent  column 
of  blood  (a)  acting  from  above,  the  resistance 
offered  by  the  next  valve  below  the  point  of  entry 
of  the  deep  vein  acting  from  below  (b),  and  the 
force  with  which  the  blood  is  driven  by  the  con- 
tracting muscles  out  of  the  deep  vein  into  the 
superficial  trunk  acting  at  an  angle  to  both  these 
lines  of  force  (c).  Unfortunately  for  the  subjects 
of  varices,  the  two  principal  veins  (the  saphenous) 
are  accompanied  by  sensory  nerves,  and  there  is 
no  doubt  that  much  of  the  pain  incident  to  vari- 
cose veins  in  the  leg  depends  upon  pressure  on 
these  nerves. 

With  reference  to  pain  in  the  leg-,  it  must 
be  remembered  that  the  nerves  that  bring  sensa- 
tion to  the  part  arise  at  a  considerable  distance 
from  their  points  of  termination,  and  that  the 
causes  of  pain  in  the  limb  may  be  situated  far 
away  from  the  seat  of  trouble.  Thus  Sir  B. 
Brodie  mentions  the  case  of  a  gentleman  who  suf- 
fered from  severe  pain  in  the  left  leg,  from  the 
foot  to  the  knee,  in  the  course  of  the  peroneal 
nerve.  No  cause  could  be  found  for  it.  At  the 
patient's  death,  however,  a  large  tumour  was 
found  attached  to  the  lumbar  spine,  which  had 
evidently  compressed  the  left  great  sciatic  nerve. 
It  is  more  difficult  to  offer  an  explanation,  based 
on  anatomical  grounds,  for  cases  such  as  those 
reported  by  Sir  William  Bennett,  where  the  re- 
moval of  a  corn  from  the  sole  of  the  foot  in  one 
instance,  and  a  tumour  from  the  leg  in  another, 
led  to  the  disappearance  of  a  pain  which  was  felt 
in  the  groin. 

There  would  appear  to  be  little  connection  be- 
tween disease  in  the  rectum  and  a  pain  in  the  leg, 
yet  in  one  case  at  least  that  connection  was 
marked.  "  Only  recently, ;;  writes  Mr.  Hilton,  "  I 
saw  a  gentleman  from  South  Wales,  who  was  the 
subject  of  stricture  of  the  rectum  from  malignant 


556  SURGICAL    APPLIED    ANATOMY      [Part  V 

disease.  He  suffered  pain  in  the  knee-joint  and 
in  the  back  part  of  the  leg.  This  led  me  to  sus- 
pect, what  really  turned  out,  upon  careful  exam- 
ination, to  be  the  case,  that  a  large  mass  of  cancer 
was  involving  the  nerves  on  the  anterior  part  of 
the  sacrum,  and  also,  no  doubt,  the  obturator 
nerve. " 

Dr.  Ralfe  mentions  cases  of  renal  calculus 
attended  by  severe  pain  in  the  sole  of  the  foot, 
and  I  have  met  with  many  instances  of  this  as- 
sociation, the  pain  being  most  commonly  in  the 
heel. 

Fractures  of  the  leg-. — Of  the  bones  of  the 
leg  the  tibia  and  fibula  are  more  often  broken 
together  than  singly,  and  of  separate  bones  the 
fibula  is  more  often  fractured  than  is  the  larger 
bone. 

1.  The  tibia  and  fibula. — As  regards  the  re- 
sistance it  offers  to  violence  the  fibula  presents 
about  the  same  degree  of  strength  in  all  its  parts, 
save  at  the  malleolus  and  at  its  upper  extremity. 
Its  great  length  and  the  manner  of  its  attachment 
to  the  tibia  (its  two  ends  being  fixed  and  its  main 
part  being  unsupported)  render  it  a  slender  bone, 
and  but  for  the  efficient  protection  it  derives  from 
the  thick  pad  of  muscles  that  surrounds  it,  it 
would  no  doubt  be  very  frequently  broken.  This 
is  all  the  more  likely  to  be  the  case,  since  the  bone 
is  placed  upon  the  more  exposed  aspect  of  the 
limb. 

The  shaft  of  the  tibia  presents  various  degrees 
of  strength,  according  as  we  regard  its  upper, 
middle,  or  lower  third.  According  to  Dr.  Leriche, 
the  average  transverse  diameter  of  the  adult 
tibia  just  below  the  tuberosities  is  a  little  over 
If  inch.  The  transverse  diameter  at  the  base  of 
the  malleolus  is  a  little  less  than  if  inch,  and 
that  of  the  narrowest  part  of  the  bone  is  a  little 
more  than  1  inch.  This  narrow  part  is  at  the 
junction  of  the  lower  with  the  middle  third  of  the 
shaft,  and  is  the  weakest  point  in  the  bone. 

The  relation  of  the  compact  to  the  cancellous 


Chap.  XXII]  THE    LEG  557 

tissue  is  about  the  same  in  all  parts  of  the  shaft ; 
but  according  to  MM.  Fayel  and  Duret,  the 
spongy  tissue  is  arranged  in  two  independent  ver- 
tical columns,  one  occupying  the  upper  two-thirds 
and  the  other  the  lower  third  of  the  bone.  The 
minimum  of  resistance  (these  authors  assert)  is 
at  the  point  where  these  two  systems  meet.  Thus 
it  happens  that  the  most  common  spot  for  a  frac- 
ture of  the  tibia  is  at  the  junction  of  _ the  middle 
with  the  lower  third  of  the  shaft.  It  is  here  that 
the  bone  yields  when  broken  by  indirect  violence, 
while  the  lesions  depending  upon  direct  violence 
may  be  at  any  part  of  the  shaft.  Owing  to  the 
thin  covering  of  soft  parts,  and  the  slight  barrier 
interposed  between  the  fracturing  force  and  the 
bone,  it  comes  to  pass  that  fractures  of  the  leg  are 
more  often  compound  and  comminuted  than  are 
those  of  any  other  bones  of  the  extremities.  If  the 
fracture  be  oblique,  as  is  commonly  the  case  when 
the  violence  is  indirectly  applied,  the  line  of 
breakage  usually  extends  from  behind,  down- 
wards, forwards,  and  a  little  inwards.  The  lower 
fragment,  with  the  foot,  is  drawn  up  behind  the 
rest  of  the  bone  by  the  muscles  of  the  calf,  and  is 
usually  displaced  also  outwards  by  the  obliquity 
of  the  fracture  line.  Often  the  lower  fragment  is 
slightly  rotated  outwards  by  the  rolling  over  of 
the  foot,  a  rotation  produced  by  the  simple  weight 
of  the  limb.  If  the  fracture  be  transverse  there 
may  be  little  or  no  displacement,  The  fibula  is 
usually  broken  at  a  higher  level  than  the  tibia, 
and  its  lower  fragment  follows,  of  course,  with 
absolute  precision  the  corresponding  fragment  of 
the  larger  bone.  A  remarkable  spiral  fracture 
(fracture  helicoide),  involving  the  lower  third  of 
the  tibia,  has  been  described  by  French  surgeons. 
It  is  associated  with  a,  more  or  less  vertical  fissure 
that  involves  the  ankle-joint,  and  with  a  fracture 
of  the  fibula  high  up.  MM.  Leriche  and  Tillaux 
have  shown  that  this  injury  is  due  to  torsion, 
especially  to  some  twisting  of  the  leg  while  the 
foot  is  fixed. 


558  SURGICAL   APPLIED    ANATOMY     [Part  V 

2.  The  fibula  alone.  Fractures  of  this  bone  in 
its  lower  fourth  are  usually  due  to  indirect  vio- 
lence, and  will  be  dealt  with  in  connection  with 
the  ankle-joint.  When  it  is  broken  in  any  other 
part  the  fracturing  force  is  usually  directly  ap- 
plied, the  lesion  transverse,  and  the  displacement 
insignificant,  or  scarcely  obvious.  The  tibia  acts 
as  an  efficient  splint. 

3.  The  tibia  alone.  The  malleolus  may  be 
broken  by  a  blow,  or  the  lower  epiphysis  separ- 
ated. The  latter  comprises  the  whole  of  the  inner 
malleolus  and  the  facet  with  which  the  fibula 
articulates.  It  joins  the  shaft  during  the  eigh- 
teenth or  nineteenth  year.  Fractures  of  the  tibia 
alone  are  nearly  always  due  to  direct  violence,  and 
whilst  most  common  in  the  lower  third  of  the  bone, 
become  more  rare  as  the  knee  is  approached. 
When  transverse  there  may  be  no  visible  displace- 
ment, the  fibula  acting  as  a  splint.  Thus  Henry 
Morris  mentions  the  case  of  a  woman  who  walked 
into  and  out  of  a  hospital  with  a  transverse  frac- 
ture of  the  tibia  that  was  not  detected  on  examina- 
tion, and  was  not  indeed  discovered  until  two  days 
after  the  accident.  When  the  fracture  is  just 
above  the  ankle  the  lower  fragment  may  be  moved 
in  whatever  direction  the  foot  is  forced,  such  dis- 
placement being  resisted  and  limited  by  the  in- 
ferior tibio-fibular  ligaments. 

In  rickets  the  tibia  is,  of  all  the  bones  of  the 
extremities,  the  one  that  most  frequently  becomes 
bent.  It  yields  at  its  weakest  part  (the  lower 
third),  and  there  the  bone  will  be  found  to  have 
developed  a  curve  forwards  and  a  little  outwards. 

Amputation  of  the  leg-  at  the  junction  of 
the  upper  with  the  middle  third  by  unequal 
antero-posterior  flaps  may  be  taken  as  an  example. 
This  is  not  the  best  method  of  amputation,  but  it 
serves  best  to  illustrate  the  anatomy  of  the  part. 
In  the  anterior  flap  the  following  structures 
would  be  cut  :  Skin,  cutaneous  nerves,  fascia, 
tibialis  _  anticus,  extensor  communis  digitorum, 
and  a  little  of  the  extensor  proprius  hallucis,  the 


Chap.  XXII] 


THE    LEG 


559 


peroneus  longus,  and  a  small  part  of  the  upper 
extremity  of  the  peroneus  brevis,  the  anterior 
tibial  vessels  and  nerve,  and  the  musculo- 
cutaneous nerve.     In  the  posterior  flap  the  follow- 


Fig.  93. — Amputation  of  leg  at  junction  of  upper  with  middle  third  by 
single  posterior  flap.    (Agatz.) 

c.  Tibia  ;  b,  fibula ;  r.  tibialis  amicus ;  (/.  ext.  com.  digit. ;  e,  peron.  long. ;  f,  tib. 
post.:  <7,  soleus  Tvith  flex.  long,  digit. ;  h,  gastrocnemius:  i,  anterior  tibial 
vessels ;  j,  post,  tibial  and  peroneal  vessels  :  k,  int.  saplien.  vein  ;  I,  post,  tibial 
nerve. 

ing  would  be  the  parts  divided  :  Skin,  external 
and  internal  saphenous  veins  and  nerves,  fascia, 
gastrocnemius,  plantaris,  soleus,  tibialis  posticus, 
flexor  longus  digitorum,  a  little  of  the  upper  end 
of  the  flexor  longus  hallucis,  the  posterior  tibial 
vessels  and-  nerve,  and  the  peroneal  vessels. 


560 


SUEGICAL    APPLIED    ANATOMY      [Part  V 


Fig.  93  shows  the  stump  leftTafter  the  amputa- 
tion through  the  lower  part  of  the  upper  third  of 
the  leg  by  means  of  a  single. flap  cut  from  the  calf. 
It  serves  to  show  the  relations  of  the  chief  parts 
divided,  and  gives  a  good  idea  of  the  stump  that 
would  be  left  in  an  amputation  by  an  anterior 
skin  flap  and  a  posterior  transfixion  flap  cut  from 
the  calf. 


c. Lj 


Fig.  94. — Transverse  section  through  the  lower  third  of  the  leg. 
(Brav  ne.) 

a,  Tibialis anticus ;  b,  extensor  longus  hallucis;  c,  extensor  communis  digitorum; 
'/,  peroneue  brevis;  e,  peroneus  longus;/  tibialis  posticus;  g,  flexor  Longus 
digitorum;  /',  flexor  Longus  hallucis;  i,  gastrocnemius  and  soleus;  ./'.  short 
saphenous  nerve  and  vein  ;  /.•,  anterior  tibial  vessels  and  nerve  ;  /,  peroneal 
vess<  Is;  m,  posterior  tibial  vessels  and  nerve;  n, musculo-cutaneous  nerve. 

In  Fig.  94  is  shown  a  transverse  section  of  the 
leg  at  the  lower  third,  from  which  can  be  gathered 
an  idea  of  the  number  and  position  of  the  parts 
cut  in  amputations  through  that  part. 

An  excellent  method  of  amputation  at  the 
upper  part  of  the  leg  is  by  a  single  external  flap 
containing  the  anterior  tibial  artery  in  its  entire 
length. 


CHAPTER    XXIII 

THE    ANKLE    AND    THE    FOOT 

Surface  anatomy. — Bony  points.  The  outlines 
of  the  two  malleoli  can  be  very  distinctly  denned. 
The  external  is  somewhat  the  less  prominent, 
descends  lower,  and  lies  farther  back  than  the 
internal  process.  The  tip  of  the  outer  malleolus 
is  about  \  an  inch  behind  and  below  the  tip  of 
the  corresponding  bony  prominence.  The  antero- 
posterior diameter,  however,  of  the  internal  mal- 
leolus is  such  that  its  posterior  border  is  on  a 
level  with  that  of  the  outer  process  behind. 

On  the  dorsum  of  the  foot  the  individual  tarsal 
bones  are  not  to  be  distinguished,  although  the 
astragalus  forms  a  distinct  projection  upon  that 
surface  when  the  foot  is  inverted. 

On  the  inner  side  of  the  foot  the  tuberosity  of 
the  os  calcis  may  be  felt  most  posteriorly.  In 
front  of  it,  and  about  1  inch  vertically  below  the 
inner  malleolus,  is  the  projection  of  the  sustenta- 
culum tali.  About  \\  inch  in  front  of  the  mal- 
leolus the  tuberosity  of  the  scaphoid  can  be  dis- 
tinctly made  out  (Fig.  97,  p.  583).  In  the  interval 
between  it  and  the  last-named  process  lies  the 
inferior  calcaneo-scaphoid  ligament,  and  the  ten- 
don of  the  tibialis  posticus.  Farther  towards  the 
front  of  the  foot  can  be  felt  the  ridge  formed  by 
the  base  of  the  first  metatarsal  bone,  and  between 
it  and  the  scaphoid  tubercle  lies  the  inner  cunei- 
form bone.  Lastly,  the  shaft  of  the  first  meta- 
tarsal bone,  its  expanded  head,  and  the  sesamoid 
2  K  561 


562  SURGICAL    APPLIED    ANATOMY      [Part  V 

bones  that  lie  on  the  plantar  aspect  of  the  meta- 
tarsal phalangeal  joint  can  be  more  or  less  dis- 
tinctly denned.  On  the  outer  side  of  the  foot  the 
external  surface  of  the  os  calcis  is  subcutaneous  in 
nearly  the  whole  of  its  extent.  Less  than  1  inch 
below  and  in  front  of  the  malleolus  is  the  peroneal 
tubercle,  with  the  short  peroneal  tendon  above  it 
and  the  long  one  below  it.  Some  2\  inches  from 
the  outer  malleolus  the  projection  of  the  base  of 
the  fifth  metatarsal  bone  is  very  evident,  and  ex- 
tending for  an  inch  or  so  behind  it  lies  the  cuboid 
bone. 

Joint  lines. — The  ankle-joint  lies  about  on  a 
level  of  a  point  \  an  inch  above  the  tip  of  the 
inner  malleolus.  Immediately  behind  the  tubercle 
of  the  scaphoid  is  the  astragalo-scaphoid  articula- 
tion, and  a  line  drawn  transversely  across  the 
dorsum  of  the  foot,  just  behind  the  process,  very 
fairly  corresponds  to  the  mid-tarsal  joint  (the 
joint  compounded  of  the  astragalo-scaphoid  and 
calcaneo-cuboid  articulations). 

If  the  latter  articulation  be  approached  from 
the  outer  side  it  will  lie  opposite  a  point  midway 
between  the  outer  malleolus  and  the  prominent 
base  of  the  fifth  metatarsal  bone. 

The  lines  of  the  articulations  between  the  first 
and  fifth  metatarsal  bones  and  the  inner  cunei- 
form and  the  cuboid  respectively  are  easily  indi- 
cated, being  placed  just  behind  the  bases  of  the 
former  bones.  The  metatarso-phalangeal  articula- 
tions are  situated  about  1  inch  behind  the  webs  of 
the  corresponding  toes.  The  proximal  phalanx 
and  part  of  the  middle  are  buried  in  the  web. 

Tendons. — The  tendo  Achillis  stands  out  very 
conspicuously  at  the  back  of  the  ankle,  and  be- 
tween it  and  the  malleoli  are  two  hollows  which 
are  evident  in  even  obese  individuals.  Over  the 
front  of  the  ankle  the  tendons  of  the  extensor 
muscles  are  readily  to  be  distinguished,  especially 
when  the  joint  is  flexed.  From  within  outwards 
they  are  :  the  tendons  of  the  tibialis  anticus,  ex- 
tensor longus  hallucis,  extensor  longus  digitorum, 


Chap.  XXIII]  ANKLE    AND    FOOT  563 

and  peroneus  tertius.  Beneath  the  tendons  of  the 
extensor  of  the  toes,  and  on  the  outer  part  of  the 
dorsum  of  the  foot,  the  prominent  fleshy  mass 
formed  by  the  extensor  brevis  digitorum  can  be 
felt  and,  when  in  action,  seen.  Above  and  behind 
the  inner  malleolus  the  tendons  of  the  tibialis 
posticus  and  flexor  longus  digitorum  can  be  dis- 
cerned, the  former  lying  nearer  to  the  bone. 
Nearer  to  the  middle  line  runs  the  flexor  longus 
hallucis.  Behind  the  outer  malleolus  the  long  and 
short  peroneal  tendons  can  be  felt,  lying  close  to 
the  edge  of  the  fibula,  the  tendon  of  the  smaller 
muscle  being  the  closer  to  it. 

In  the  middle  of  the  sole  of  the  foot  the  resist- 
ing plantar  fascia  can  be  felt,  and  some  of  its 
processes  made  out  when  the  toes  are  drawn  up  by 
the  extensors.  The  fleshy  mass  on  the  inner 
margin  of  the  foot  is  formed  by  the  abductor  and 
flexor  brevis  hallucis ;  that  on  the  outer  side  by 
the  abductor  and  flexor  brevis  minimi  digiti. 

Vessels. — The  anterior  tibial  artery  and  nerve 
are  placed  opposite  the  ankle-joint,  between  the 
tendons  of  the  extensor  proprius  hallucis  and 
longus  digitorum.  The  dorsal  artery  runs  from 
the  middle  of  the  ankle  to  the  interval  between 
the  bases  of  the  first  and  second  metatarsal  bones. 
It  may  be  felt  pulsating  against  the  bones  along 
the  outer  side  of  the  extensor  proprius  hallucis 
tendon,  which  is  the  readiest  guide  to  it.  The 
plantar  arteries  start  from  a  point  midway  be- 
tween the  tip  of  the  malleolus  internus  and  the 
centre  of  the  convexity  of  the  heel.  The  internal 
vessel  follows  a  line  drawn  from  this  point  to  the 
middle  of  the  under  surface  of  the  great  toe.  The 
external  vessel  crosses  the  sole  obliquely  to  within 
a  thumb's  breadth  of  the  base  of  the  fifth  meta- 
tarsal bone.  From  thence  it  turns  more  trans- 
versely across  the  foot,  running  inwards  over  the 
bases  of  the  metatarsal  bones  to  inosculate  with 
the  dorsalis  pedis  artery  at  the  back  of  the  first 
interosseous  space.  On  the  dorsum  of  the  foot  the 
subcutaneous  veins  may  be  seen  forming  an  arch 


564  SUEGICAL    APPLIED    ANATOMY      [Part  V 

convex  towards  the  toes,  and  from  the  ends  of  the 
arch  vessels  may  be  followed  into  the  internal  and 
external  saphenous  veins. 

The  ankle  and  foot.-^The  skin  about  the 
ankle  and  over  the  dorsum  of  the  foot  is  thin  and 
but  loosely  attached  to  the  subjacent  parts.  It  be- 
comes readily  excoriated,  as  is  often  the  case  where 
splints  or  instruments  have  been  improperly 
applied.  Since  the  skin  over  the  malleoli  lies 
directly  upon  the  bone,  while  that  covering  the 
dorsum  of  the  foot  is  but  slightly  separated  from 
the  bones  of  the  tarsus,  it  follows  that  the  integu- 
ments in  this  region  are  readily  contused,  and 
may  suffer  gangrene  from  an  amount  of  pressure 
that  would  cause  but  little  trouble  in  other  parts. 
Over  the  sole  the  integument  is  dense  and  thick  in 
all  those  parts  that  come  in  contact  with  the 
ground.  In  the  normal  foot,  the  heel,  the  outer 
margin  of  the  foot,  and  the  line  of  metatarso- 
phalangeal joints  are  in  contact  with  the  ground 
when  the  sole  is  placed  flat  upon  it  (Fig.  98, 
p.  585). 

The  subcutaneous  tissue  about  the  ankle  and 
foot  varies  greatly  both  in  quantity  and  charac- 
ter. Over  the  front  of  the  ankle  and  dorsum  of 
the  foot  it  is  very  lax,  free  from  fat,  and  is  the 
first  part  to  be  infiltrated  in  general  dropsy  of 
the  body.  On  the  sole  the  subcutaneous  tissue  is 
dense,  firm,  and  studded  with  pellets  of  fat.  It  is 
|  of  an  inch  thick  over  the  heel. 

The  integuments  of  the  foot  are  well  supplied 
with  nerves,  being  furnished  with  branches  from 
no  less  than  six  nerve  trunks,  the  musculo-cutane- 
ous,  the  anterior  tibial,  the  two  saphenous,  and 
the  external  and  internal  plantar.  Many  Paci- 
nian bodies  are  found  upon  these  cutaneous 
branches,  and  end-bulbs  are  met  with  in  the  skin 
on  the  sole.  The  integuments  of  the  foot  respond 
acutely  to  sensations  of  pain,  of  pressure,  of  tem- 
perature, and  to  certain  unwonted  forms  of  tac- 
tile impression,  such  as  tickling.  Tactile  sensi- 
bility, however,  as  measured  by  the  sesthesio  meter, 


Chap.  XXIII]  ANKLE    AND    FOOT  565 

is  not  acute,  the  dorsum  of  the  foot  showing,  in 
regard  to  this  matter,  no  more  sensitiveness  than 
does  the  skin  of  the  buttock. 

Over  the  "  tread  of  the  foot,"  and  especially 
under  the  ball  of  the  great  toe,  the  peculiar 
affection  known  as  "  perforating  ulcer "  is  most 
commonly  met  with.  This  ulcer  occurs  as  an 
occasional  symptom  in  certain  nerve  maladies, 
and  particularly  in  locomotor  ataxy. 

The  fascia;  of  the  foot  and  the  tendons 
about  the  ankle. — The  fasciae  on  the  dorsum 
occur  in  two  layers,  a  superficial  one  that  is  con- 
tinued from  the  anterior  annular  ligament,  and  a 
deeper  placed  over  the  extensor  brevis  and  inter- 
ossei  muscles.  These  membranes  are  both  thin  and 
insignificant,  and  exercise  no  influence  from  a 
surgical  point  of  view.  The  plantar  fascia  is 
divided  into  three  parts,  a  central  or  main  por- 
tion which  is  extremely  dense  and  powerful,  and 
two  lateral  expansions  which  are  thin  and  surgi- 
cally insignificant.  The  outer  of  the  two  lateral 
portions  is,  however,  of  some  substance,  and  forms 
a  very  thick  band  between  the  os  calcis  and  fifth 
metatarsal  bone,  that  may  become  rigidly  con- 
tracted in  some  forms  of  talipes.  The  central  ex- 
pansion assists  greatly  in  supporting  the  antero- 
posterior arch  of  the  foot,  which  it  tends  to  main- 
tain in  the  manner  that  the  bowstring  maintains 
the  arch  of  the  bow. 

The  sinking  of  the  arch  that  occurs  in  "  flat 
foot ;;  is  associated  with  marked  yielding  of  this 
fascia.  The  plantar  fascia  is  often  found  much 
contracted  (as  a  rule,  secondarily)  in  certain 
forms  of  club-foot,  such  as  talipes  equinus  and 
congenital  varus.  The  term  "  talipes  cavus  ;;  is 
applied  to  a  deformity  that  depends  mainly  or 
entirely  upon  a  contraction  of  the  plantar  fascia. 
The  best  place  in  which  to  divide  this  membrane 
is  at  a  spot  about  1  inch  in  front  of  its  attachment 
to  the  os  calcis.  This  is  its  narrowest  part,  and 
the  knife  (which  should  be  introduced  from  the 
inner  side)   will  be  behind  the   external   plantar 


566  SURGICAL   APPLIED   ANATOMY     [Part  t 

artery  which  runs  beneath  the  expansion.  An 
abscess  situated  beneath  the  membrane  will  be  very 
closely  bound  down,  and  will  advance  in  any 
direction  other  than  through  the  membrane  itself 
so  as  to  point  in  the  centre  of  the  sole.  Such  deep 
collections  cause  intense  pain,  and  often  much 
destruction,  before  they  are  discharged.  They 
may  open  upon  the  dorsum,  or  may  extend  up 
along  the  tendons  to  the  region  of  the  ankle. 
There  are  certain  foramina  or  spaces  in  the  sub- 
stance of  this  layer  occupied  usually  by  fat. 
Through  one  or  more  of  these  an  abscess  will,  in 
exceptional  cases  extend,  and  then  spread  out  be- 
neath the  integuments.  Such  an  abscess  will  have, 
therefore,  two  cavities  united  by  a  small  hole,  and 
will  form  the  abces  en  bissac  or  en  bouton^  de 
chemise  of  the  French.  The  plantar  fascia  divides 
into  slips  near  the  roots  of  the  toes,  and  forms  a 
series  of  arches,  beneath  which  pass  the  tendons, 
vessels,  and  nerves  bound  for  the  digits.  Two 
intermuscular  septa  connected  with  the  membrane 
separate  the  flexor  brevis  digitorum  from  the  ab- 
ductor hallucis  on  the  one  side  and  the  abductor 
minimi  digiti  on  the  other.  They  are,  however, 
membranes  of  too  feeble  a  structure  to  affect  much 
the  progress  of  a  deep  plantar  abscess. 

The  anterior  annular  ligament  is  divided  into 
two  parts ;  an  upper  band  in  front  of  the  tibia  and 
fibula,  and  a  lower  band  in  front  of  the  upper 
limits  of  the  tarsus.  Beneath  the  former  there  is 
only  one  synovial  sheath,  that  for  the  tibialis 
anticus ;  beneath  the  latter  are  three  sheaths  :  one 
for  the  peroneus  tertius  and  extensor  communis, 
one  for  the  extensor  proprius  pollicis,  and  a  third 
for  the  tibialis  anticus. 

According  to  Holden,  there  is  often  a  large 
irregular  bursa  between  the  tendons  of  the  ex- 
tensor longus  digitorum  and  the  projecting  end 
of  the  astragalus.  This  bursa  sometimes  communi- 
cates with  the  joint  at  the  head  of  the  astragalus. 

Beneath  the  internal  annular  ligament  are 
three    synovial    sheaths    for    the    tendons    of    the 


Chap.  XXIII]  ANKLE    AND    FOOT  60? 

tibialis  posticus,  flexor  longus  digitorum,  and 
flexor  longus  hallucis.  Inflammation  involving 
the  sheath  for  the  tibialis  posticus  may  spread  to 
the  ankle-joint,  with  which  the  tendon  is  in  close 
relation.  Beneath  the  outer  annular  ligament  is 
the  single  synovial  sheath  for  the  long  and  short 
peroneal  tendons. 

In  severe  sprains  of  the  ankle  not  only  are  the 
ligaments  about  the  joint  more  or  less  ruptured, 
but  the  various  synovial  sheaths  just  named  are 
apt  to  be  torn  and  filled  with  blood.  The  long 
abiding  trouble  in  the  part  that  often  follows 
severe  sprains  depends  to  a  great  extent  upon 
damage  to  these  sheaths,  and  to  extravasations  of 
blood,  and  subsequently  of  inflammatory  material, 
within  them.  These  sheaths  are  more  extensive 
than-is  usually  supposed;  those  at  the  inner  side 
of  the  ankle  commence  from  one  to  two  inches 
above  the  malleolus,  and  extend  into  the  sole  of 
the  foot  to  a  point  opposite  the  tuberosity  of  the 
scaphoid.  Those  at  the  outer  side  of  the  ankle  are 
even  more  extensive,  that  round  the  peroneus 
longus  extending  to  the  base  of  the  first  meta- 
tarsal, although  occasionally  the  plantar  and  mal- 
leolar parts  may  be  found  completely  separated 
from  each  other  at  the  outer  border  of  the  cuboid. 
From  the  length  of  the  sheaths  it  can  be  readily 
understood  that  the  adhesions  which  follow 
sprains  and  fractures  at  the  ankle  are  very  ex- 
tensive, unless  passive  movements  be  carried  out 
to  prevent  their  formation. 

There  are  few  bursae  of  any  magnitude  about 
the  foot,  save  one  between  the  tendo  Achillis  and 
os  calcis,  and  another  over  the  metatarso-phalan- 
geal  joint  of  the  great  toe.  The  first-named  bursa 
rises  up  about  ^  an  inch  above  the  os  calcis,  and 
bulges  out  on  either  side  of  the  tendon.  When  in- 
flamed it  may  produce  symptoms  like  those  of 
ankle-joint  disease,  and  when  suppurating  may 
lead  to  caries  of  the  os  calcis.  The  enlargement  of 
the  bursa  over  the  metatarso-phalangeal  joint  of 
the  great  toe  constitutes  a  bunion.     It  lies  in  the 


568  SURGICAL    APPLIED    ANATOMY      [Part  V 

subcutaneous  tissue  between  the  internal  sesamoid 
and  the  skin,  and  is  not  present  at  birth.  This 
condition  is  generally  brought  about  by  impro- 
perly shaped  boots,  which  force  the  great  toe  out- 
wards, place  it  obliquely  to  the  long  axis  of  the 
foot,  and  render  the  metatarsal  joint  very  promi- 
nent. The  cartilage  over  the  inner  part  of  the 
head  of  the  metatarsal  bone  disappears,  and  a 
communication  between  the  bursa  and  joint  may 
be  set  up.  The  result  of  this  deformity  is  a  great 
weakening  of  the  toe  and  adjacent  part  of  the 
foot,  a  lengthening  of  the  internal  lateral  liga- 
ment of  the  joint,  and  a  displacement  outwards  of 
the  tendon  of  the  extensor  proprius  hallucis. 
Bursse  are  often  developed  over  the  malleoli  in 
tailors,  and  especially  over  the  external  process, 
the  part  most  pressed  upon  when  sitting  cross- 
legged.  In  club-foot,  bursse  are  found  over  any 
points  that  are  exposed  to  undue  pressure. 

The  tendons  about  the  ankle  are  not  unfre- 
quently  ruptured  by  violence.  Those  that  most 
often  are  so  injured  are  the  tendo  Achillis  and  the 
tendons  of  the  tibialis  posticus,  and  long  and 
short  peroneal  muscles.  The  tendo  Achillis  usually 
breaks  at  a  point  about  l\  inch  above  its  inser- 
tion, where  it  becomes  narrowed  and  its  fibres 
collected  into  a  very  definite  bundle. 

In  some  forms  of  violence  the  synovial  and 
fibrous  sheaths  that  bind  down  a  tendon  may  be 
ruptured  and  it  may  be  allowed  to  become  dis- 
placed. This  has  happened  to  the  tibialis  posticus 
and  peroneal  muscles.  In  each  instance  the  dis- 
located structure  comes  forward  upon  or  in  front 
of  the  malleolus.  No  tendon  in  the  body  is  so 
frequently  displaced  as  is  that  of  the  peroneus 
longus. 

The  tendons  about  the  ankle  are  frequently 
divided  by  operation.  The  tendo  Achillis  is 
usually  cut  about  1  inch  above  its  insertion,  the 
knife  being  entered  from  the  inner  side  to  avoid 
the  posterior  tibial  vessels.  The  tibialis  posticus 
tendon  is,  as  a  rule,  divided  just  above  the  base  of 


Chap.  XXIII]  ANKLE    AND    FOOT  569 

the  inner  malleolus.  There  is,  however,  enough 
room  between  the  annular  ligament  and  the  sca- 
phoid bone  to  cut  it  on  the  side  of  the  foot  (Fig. 
97,  p.  583).  The  anterior  tibial  tendon  may  be 
divided  readily  either  in  front  of  the  ankle  or  at 
its  insertion  into  the  internal  cuneiform  bone.  On 
section  of  a  tendon  a  gap  is  felt,  owing  to  retrac- 
tion by  the  muscle.  The  cut  ends  are  still  united 
by  the  fibrous  tissue  in  which  they  lie,  and  from 
which  they  derive  their  blood  supply.  If  cut 
within  a  sheath  the  synovial  membrane  forms  a 
loose  binding  between  the  cut  ends.  A  fibrous 
band  between  the  cut  ends  is  ultimately  formed 
from  the  effusion  which  fills  the  gap.  The  new 
band  is  firmly  adherent  to  the  sheath  in  which  it 
lies,  and  at  first  will  limit  the  movements  of  the 
tendon. 

Part  of  the  tendon  of  a  sound  muscle  may  be 
yoked  to  that  of  one  which  has  become  paralysed, 
thus  restoring  certain  movements  to  the  foot. 

Blood-vessels. — The  lines  of  the  various 
arteries  have  been  already  indicated.  Wounds  of 
the  plantar  arch  are  serious,  on  account  of  the 
depth  at  which  the  external  plantar  artery  lies, 
and  the  impossibility  of  reaching  the  vessel  with- 
out making  a  large  wound  in  the  sole  that  would 
open  up  important  districts  of  connective  tissue 
and  do  damage  to  tendons  and  nerves.  The  arch 
is  formed  by  the  junction  of  the  external  plantar 
artery  with  the  dorsal  artery  of  the  foot,  a  con- 
tinuation of  the  anterior  tibial  vessel.  In  cases, 
however,  of  bleeding  from  the  arch,  ligature  of 
both  the  posterior  and  anterior  tibial  vessels  at  or 
just  above  the  ankle  would  not  necessarily  arrest 
the  haemorrhage.  After  ligature  of  these  vessels 
blood  would  still  be  brought  indirectly  to  the  arch 
by  means  of  the  peroneal  artery.  By  its  anterior 
peroneal  branch  this  vessel  communicates  with  the 
external  malleolar  branch  of  the  anterior  tibial 
artery,  and  with  the  tarsal  branch  of  the  dorsalis 
pedis.  By  its  terminal  branch  it  communicates 
with  the  two  last-named  vessels,  and  also  with  the 


570  SURGICAL    APPLIED    ANATOMY      [Part  V 

internal  calcaneal  branches  of  the  external  plan- 
tar artery.  As  a  matter  of  practice,  however, 
elevation  of  the  limb,  together  with  pressure  upon 
the  wounded  point  and  compression  of  the  main 
artery,  are  sufficient  to  check  most  haemorrhages 
from  the  plantar  arch. 

The  dorsalis  pedis  artery,  from  its  superficial 
position  and  its  close  contact  with  the  bones  of  the 
foot,  is  frequently  divided  in  wounds  and  rup- 
tured in  severe  contusions.  The  posterior  tibial 
artery  at  the  ankle  is  well  protected  by  the  pro- 
jecting malleolus,  the  dense  annular  ligament,  and 
the  tendons  that  run  by  its  side. 

The  superficial  veins  of  the  foot,  like  those  of 
the  hand,  are  found  mainly  upon  the  dorsum  of 
the  member.  The  sole,  as  a  part  exposed  to  pres- 
sure, is  singularly  free  from  them.  About  the 
malleoli,  and  especially  about  the  inner  process, 
these  veins  form  a  considerable  plexus.  Hence  it 
is  that  appliances  that  fit  tightly  around  the  ankle 
are  apt  to  produce  oedema  and  pain  in  the  parts 
beyond.  The  dull  pain  in  the  feet  that  is  often 
caused  by  tight  elastic-side  boots  is  probably  due 
to  the  same  cause. 

The  lymphatics  form  a  very  fine  and  elabo- 
rate plexus  in  the  coverings  of  the  sole,  from 
which  vessels  arise  that  reach  the  borders  and  dor- 
sum of  the  foot,  and  principally  the  inner  border. 
The  main  lymph  vessels  of  the  part  are  found 
upon  the  dorsum,  about  the  radicles  of  the  two 
saphenous  veins.  Those  on  the  inner  side  of  the 
foot  are  by  far  the  more  numerous ;  they  follow 
pretty  generally  the  course  of  the  internal  saphe- 
nous vein,  and  end  in  the  inguinal  glands.  The 
external  vessels  pass  up  along  the  outer  ankle  and 
outer  side  of  the  leg.  The  bulk  of  them  pass 
obliquely  across  the  ham  to  join  the  inner  set 
above  the  knee ;  others  reach  the  inner  set  by  cross- 
ing the  front  of  the  tibia,  while  a  few  follow  the 
short  saphenous  vein  and  end  in  th«3  popliteal 
glands  (see  p.  531). 

The  ankle-joint  is  a  very  powerful  articula- 


OKap.  XXIII]  ANKLE    AND    FOOT  571 

tion,  its  strength  being  derived  not  only  from  the 
shape  of  its  component  bones,  but  also  from  the 
unyielding  ligaments  and  many  tendons  that  are 
bound  about  it  like  straps.  Of  the  ligaments,  the 
two  lateral  are  very  strong,  and  have  an  extensive 
hold  upon  the  foot.  The  anterior  and  posterior 
are  extremely  thin  and  insignificant,  although  the 
latter  is  supported  by  the  tendon  of  the  flexor 
longus  hallucis,  which  crosses  it.  When  effusion 
takes  place  into  the  joint,  it  first  shows  itself  in 
front,  beneath  the  extensor  tendons,  and  just  in 
front  of  the  lateral  ligaments.  This  is  due  to  the 
feebleness  of  the  anterior  ligament  and  the  extent 
and  looseness  of  the  synovial  sac  in  relation  with 
that  structure.  More  extensive  effusions  cause  a 
bulging  behind  through  yielding  of  the  thin  pos- 
terior part  of  the  capsule,  and  fluctuation  can 
then  be  obtained  on  either  side  of  the  tendo 
Achillis.  In  no  ordinary  case  can  fluctuation  be 
detected  distinctly  beneath  the  unyielding  lateral 
ligaments.  Moreover,  the  loose  synovial  sac  of  the 
ankle-joint  extends  both  in  front  and  behind  be- 
yond the  limits  of  the  articulation,  while,  at  the 
sides,  it  is  strictly  limited  to  the  joint  surfaces. 
The  ankle  is  a  perfect  hinge-joint,  and  permits 
only  of  flexion  and  extension.  The  very  slightest 
amount  of  lateral  movement  is  allowed  in  extreme 
extension,  when  the  narrower,  or  hinder,  part  of 
the  astragalus  is  brought  into  contact  with  tne 
widest,  or  anterior,  part  of  the  tibio-fibular  arch. 
When  obvious  lateral  movement  exists  at  the 
ankle,  the  joint  must  be  the  seat  of  either  injury 
or  disease;  and  it  is  important  not  to  mistake  the 
lateral  movements  permitted  between  certain  of 
the  tarsal  bones  for  movements  at  the  ankle-joint. 
Dorsi-flexion  is  limited  by  the  posterior  and 
middle  parts  of  the  internal  ligament,  by  the  pos- 
terior part  of  the  external  ligament,  by  the  pos- 
terior ligament,  and  by  the  contact  of  the  astra- 
galus with  the  tibia.  Plantar  flexion  is  limited  by 
the  anterior  fibres  of  the  inner  ligament,  the 
anterior  and  middle  parts  of  the  outer  ligament, 


572  SURGICAL   APPLIED   ANATOMY     [Part  V 

by  the  anterior  part  of  the  capsule,  and  the  con- 
tact of  the  astragalus  with  the  tibia. 

Owing  to  its  exposed  position,  this  joint  is 
very  liable  to  become  inflamed  from  injury  or 
other  external  causes.  When  inflamed,  no  dis- 
tortion is,  as  a  rule,  produced,  the  foot  remaining 
at  right  angles  with  the  leg.  It  would  appear 
that  this  position  is  due  to  the  circumstances  that 
the  flexor  and  extensor  muscles  about  balance  one 
another,  and  it  does  not  seem  that  the  capacity  of 
the  joint  is  affected  by  the  posture  of  the  foot. 
The  synovial  cavity  of  the  ankle  is  in  communica- 
tion with  the  inferior  tibio-fibular  articulation. 

In  connection  with  the  subject  of  "  referred 
pains,"  it  should  be  remembered  that  the  nerves 
supplying  the  ankle-joint  bring  that  articulation 
into  relation  with  the  lumbar  segments  of  the 
spinal  cord  through  the  internal  saphenous,  and 
the  sacral  segments  through  the  anterior  tibial 
nerve. 

Dislocations  at  the  ankle-joint. — The  foot 
may  be  dislocated  at  the  ankle  in  five  directions, 
which,  placed  in  order  of  frequency,  are,  out- 
wards, inwards,  backwards,  forwards,  and  up- 
wards between  the  tibia  and  fibula.  These  dis- 
locations_  are  nearly  always  associated  with  frac- 
ture of  either  the  tibia  or  fibula  or  of  both  bones. 
1.  The  lateral  dislocations:  Outwards,  in- 
wards. These  luxations  differ  somewhat  from 
those  met  with  in  other  joints.  In  the  great 
majority  of  cases  they  consist  of  a  lateral  twisting 
of  the  foot,  of  such  a  kind  that  the  astragalus  is 
rotated  beneath  the  tibio-fibular  arch.  There  is 
no  great  removal  of  the  upper  surface  of  the  astra- 
galus from  that  of  the  tibia,  one  or  other  edge  of 
the  former  bone  being  brought  in  contact  with  the 
horizontal  articular  surface  of  the  latter. 
Although  much  deformity  is  produced,  the  actual 
separation  of  the  foot  from  the  leg  is  not  con- 
siderable. In  some  rare  cases  a  true  lateral  dis- 
location in  the  horizontal  direction  has  been  met 
with. 


Chap.  XXIII] 


ANKLE    AND    FOOT 


573 


These  injuries  are  due  to  sudden  and  violent 
twistings  of  the  foot,  and  are  in  nearly  every  in- 
stance associated  with  fractures  of  the  tibia  or 
fibula.  The  luxation  outwards  is  due  to  forcible 
eversion  of  the  foot,  the  luxation  inwards  to  vio- 
lent inversion. 


Fig.  95. — Diagrams  to  illustrate  the  mechanism  involved  in  fractures  of 
the  lower  end  of  the  fibula. 

A,  Parts  in  normal  position;  a,  tibio-fibular  ligaments;  b,  external  lateral  liga- 
ment ;  c,  internal  lateral  ligament.  B,  fracture  of  fibula  due  to  eversion  of 
foot.   C,  fracture  of  fibula  due  to  inversion  of  foot. 

It  is  of  interest,  in  the  first  place,  to  note  the 
relation  of  the  fibula  to  injuries  at  the  ankle- 
joint,  especially  as  a  fracture  of  the  lower  end  of 
the  shaft  of  that  bone  may  follow  alike  upon  both 
inversion  and  eversion  of  the  foot.  The  lower  3 
or  4  inches  of  the  fibula  may  be  considered  to  form 
a  lever  of  the  first  kind  (Fig.  95,  a).  The  fulcrum 
is   at  the   inferior   tibio-fibular   articulation,   one 


574  SUKGICAL    APPLIED    ANATOMY      [Part  V 

arm  of  the  lever  is  the  malleolus  below  that  joint, 
while  the  other  arm  may  be  regarded  as  formed 
by  the  lower  2  or  3  inches  of  the  shaft  of  the  bone. 
Now  the  lower  ends  of  the  tibia  and  fibula  are 
bound  together  by  very  powerful  ligaments,  viz., 
the  anterior  and  posterior  tibio-fibular,  the  trans- 
verse, and  the  inferior  interosseous.  I  would  ven- 
ture to  insist  particularly  that  in  no  ordinary 
lesion  about  the  ankle,  whether  fracture  or  dis- 
location, do  these  ligaments  give  way.  If  they 
should  yield,  then  an  anomalous  form  of  fracture 
or  luxation  will  be  produced.  In  forcible  eversion 
of  the  foot,  the  internal  lateral  ligament  becomes 
stretched  and  tears,  the  astragalus  is  rotated 
laterally  beneath  the  tibio-fibular  arch  and  is 
brought  into  violent  contact  with  the  end  of  the 
outer  malleolus.  This  process  is  pushed  outwards, 
and  acts  as  one  end  of  a  lever.  The  fulcrum  is 
secured  by  the  unyielding  tibio-fibular  ligaments, 
and  the  fibula  breaks  at  the  other  end  of  the  lever, 
a  point  some  2  or  3  inches  above  the  end  of  the 
bone  (Fig.  95,  b).  In  forcible  inversion  of  the 
foot,  the  astragalus  undergoes  a  little  lateral  rota- 
tion in  the  opposite  direction  ;  the  external  lateral 
ligament  is  greatly  stretched,  and  tends  to  drag 
the  end  of  the  outer  malleolus  inwards.  If  the 
ligament  yields,  the  case  will  probably  end  as  a 
sprained  ankle,  or  pass  on  to  a  dislocation  in- 
wards of  the  foot.  But  if  it  remains  firm,  the  end 
of  the  fibular  lever  (the  tip  of  the  malleolus)  is 
drawn  towards  the  middle  line,  the  fulcrum  is 
secured  by  the  fcibio-fibular  ligaments,  and  the 
shaft  breaks  at  the  other  end  of  the  lever,  some 
few  inches  above  the  end  of  the  bone  (Fig.  95,  c). 
It  will  be  seen  that  in  the  fracture  due  to  eversion 
the  upper  end  of  the  lower  fragment  is  displaced 
towards  the  tibia,  while  in  the  lesion  due  to  in- 
version it  is  displaced  from  that  bone.  From  a 
careful  examination  of  all  the  cases  of  fracture  of 
the  lower  end  of  the  fibula  admitted  into  the 
London  Hospital  during  the  time  I  held  the  post 
of  surgical  registrar  there,  I  convinced  myself  that 


Chap.  XXIII]  ANKLE    AND    FOOT  575 

the  lesion  is  much  more  frequently  due  to  eversion 
than  to.  inversion  of  the  foot.  I  think  it  may  be 
said  that  a  fracture  of  the  lower  end  of  the  fibula 
due  to  simple  inversion  of  the  foot  is  not  possible 
unless  the  external  lateral  ligament  remains 
entire. 

In  the  outward  luxation,  better  known  as 
Pott's  fracture,  the  condition  is  such  as  has  just 
been  described  in  connection  with  the  effects  of 
eversion  of  the  foot  upon  the  fibula.  That  bone  is 
always  broken  some  2  or  3  inches  above  the  malle- 
olus, the  deltoid  ligament  is  torn,  or  the  tip  of 
the  inner  malleolus  wrenched  off.  The  astragalus 
is  so  rotated  laterally  that  the  foot  is  much 
everted,  its  outer  edge  raised,  while  its  inner 
edge  rests  upon  the  ground.  The  inferior  tibio- 
fibular ligaments  remain  intact.  If  they  yield,  an 
unusual  form  of  fracture  or  dislocation  is  pro- 
duced, as  already  stated.  Boyer  relates  a  case, 
considered  to  be  unique,  where  the  foot  was  lux- 
ated outwards,  but  without  any  fracture  of  the 
fibula.  That  bone,  however,  had  been  forced  up- 
wards entire,  and  its  head  dislocated  from  the 
articular  facet  of  the  tibia.  A  horizontal  disloca- 
tion outwards,  without  rotation  of  the  foot  and 
without  fracture  of  the  fibula,  is  possible  if  the 
inferior  tibio-fibular  ligaments  are  entirely  torn. 

In  Dupuytren's  fracture  (a  rare  injury)  the 
fibula  is  fractured  from  1  to  3  inches  above  the 
malleolus,  the  inferior  tibio-fibular  ligaments  are 
entirely  lacerated,  or  the  portion  of  the  tibia  to 
which  they  are  attached  is  torn  away,  and  remains 
connected  with  the  lower  fragments  of  the  fibula. 
The  foot  is  dislocated  horizontally  outwards,  and 
is  drawn  upwards,  the  extent  of  the  upward  dis- 
placement depending  upon  the  height  at  which  the 
fibula  breaks. 

In  the_  inward  luxation  the  external  lateral 
ligament  is  torn  or  the  tip  of  the  outer  malleolus 
dragged  away,  the  deltoid  ligament  is  intact,  but 
the  internal  malleolus  is  commonly  broken  by  the 
violence  with  which  the  astragalus  is  brought  into 


576  SUKGICAL    APPLIED    ANATOMY      [Part  V 

contact  with  it.  That  bone  itself  may  be  broken, 
and  is  in  any  case  rotated  laterally,  so  that  the 
foot  is  inverted  and  its  inner  border  much  raised. 
In  all  forms  of  this  dislocation,  whether  simple 
or  complicated,  the  inferior  tibio-fibular  ligament 
remains  intact. 

2.  The  antero-posterior  dislocations :  Back- 
wards; forwards.  These  injuries  are  brought 
about  by  great  force  applied  to  the  foot  while  the 
leg  is  fixed,  or  more  commonly  by  sudden^  arrest 
of  the  foot  during  some  violent  impulse  given  to 
the  body,  as  on  jumping  from  a  carriage  when 
in  motion.  In  the  luxation  backwards  the  astra- 
galus is  displaced  behind  the  tibia,  while  the 
articular  surface  of  the  latter  bone  rests  upon 
the  scaphoid  and  cuneiform  bones.  The  anterior 
and  posterior  ligaments  are  entirely  torn,  and  a 
great  part  also  of  the  two  lateral  bands.  The 
fibula  is  broken  some  2  or  3  inches  above  the  mal- 
leolus, and  there  is  usually  a  fracture  also  of  the 
inner  malleolus. 

The  luxation  forwards  is  of  extreme  rarity. 
In  the  few  reported  cases  one  or  both  malleoli 
were  broken.  R.  W.  Smith  believes  that  the  dis- 
location is  never  complete. 

3.  The  dislocation  upwards.  In  this  rare  acci- 
dent the  inferior  tibio-fibular  ligaments  are  rup- 
tured, the  two  bones  are  widely  separated  at  their 
lower  ends,  and  the  astragalus  is  driven  up  be- 
tween them.  The  anterior  and  posterior  ligaments 
are  entirely  ruptured,  but  the  lateral  ligaments 
usually  escape  with  but  some  slight  laceration. 
The  accident  appears  to  be  generally  caused  by 
a  fall,  the  patient  alighting  flat  upon  the  soles  of 
the  feet.  Mr.  Bryant  records  a  case  in  which 
both   feet   were   similarly   dislocated   upwards. 

The  foot. — There  are  two  arches  in  the  foot, 
an  antero-posterior  and  a  transverse. 

1.  The  antero-posterior  arch  has  its  summit  at 
the  astragalus.  It  may  be  considered  as  composed 
of  two  piers.  The  hinder  pior  consists  of  the  os 
calcis,   the  anterior   pier  of  the  scaphoid,   cunei- 


Ohap.  XXIII]       ANKLE    AND    FOOT 


577 


form  and  metatarsal  bones.  The  astragalus  forms 
the  keystone  of  the  arch,  the  head  of  the  bone 
especially  performing  that  function  (Fig.  96). 

The  foot  rests  upon  the  heel,  the  heads  of  the 
metatarsal  bones,  and  the  outer  margin  of  the  foot 
(Fig.  98).  The  hinder  pier  is  solid,  is  made  up  of 
a  strong  bone,  and  contains  only  one  joint.  It 
serves  to  support  the  main  part  of  the  weight  of 
the  body,    and  gives  a  firm  basis   of   attachment 


Fig.  96. — Antero- posterior  section  of  the  foot.    (Rudihger.) 

1.  Tibia  ;  2,  astragalus  ;  3,  os  calcis  ;  4,  scaphoid  ;  5,  int.  cuneiform  ;  h,  first  meta- 
tarsal  bone;  7  and  8;  phalanges  of  great  too. 

to  the  muscles  of  the  calf.  The  anterior  part  of 
the  arch,  on  the  other  hand,  contains  many  small 
bones  and  a  number  of  complicated  joints.  It 
serves  to  give  elasticity  to  the  foot,  and  to 
diminish  the  effect  of  shocks  received  upon  the 
sole  of  the  foot.  The  comparative  value  of  the 
two  piers  of  the  arch  in  this  latter  respect  can  be 
estimated  by  jumping  from  a  height  and  alight- 
ing first  upon  the  heels  and  then  upon  the  balls 
of  the  toes.  The  inner  part  of  the  arch  is  much 
more  curved  than  the  outer,  and  forms  the  in- 
step. 

%  L 


578  SUEGICAL   APPLIED    ANATOMY      [Part  V 

2.  The  transverse  arch  is  most  marked  across 
the  cuneiform  bones.  It  gives  much  elasticity  to 
the  foot  and  affords  protection  to  the  vessels  of  the 
sole. 

These  two  arches  result  from  the  shape  of  the 
component  bones,  and  are  maintained  by  the  vari- 
ous ligaments  and  muscles  of  the  sole.  The  peron- 
eus  longus  tendon,  and  nearly  all  the  ligaments 
which  connect  the  first  and  second  rows  of  tarsal 
bones  on  both  the  plantar  and  dorsal  aspects,  are 
inclined  forwards  and  inwards,  and  by  this  ar- 
rangement are  well  adapted  to  maintain  the  in- 
tegrity of  the  transverse  as  well  as  of  the  antero- 
posterior  arch. 

The  movements  of  inversion  and  eversion, 
whereby  the  foot  is  adapted  to  the  ground  on 
which  it  treads,  occur  at  the  subastragaloid 
joints.  These  are  two  in  number  :  (1)  the  anterior 
subastragaloid  joint  between  the  head  of  the  astra- 
galus and  three  other  parts,  (a)  sustentaculum 
tali;  (6)  inferior  calcaneo-scaphoid  ligament; 
(c)  scaphoid  (Fig.  96)  ;  (2)  posterior  subastra- 
galoid between  the  body  of  the  astragalus  and  os 
calcis.  The  posterior  is  separated  from  the  an- 
terior joint  by  the  interosseous  ligament.  A  third 
joint  is  also  concerned  in  these  important  move- 
ments, viz.  that  between  theos  calcis  and  cuboid. 
The  muscles  which  produce  inversion  are  (l)  tibi- 
alis posticus,  (2)  tibialis  anticus.  The  first  pro- 
duces inversion  with  plantar  flexion,  the  second 
with  dorsal  flexion.  The  flexor  muscles  of  the 
toes  assist  the  first,  the  extensor  of  the  great  toe 
the  second.  Eversion  is  produced  by  (1)  peroneus 
longus,  (2)  peroneus  brevis,  (3)  peroneus  tertius, 
(4)  the  extensor  longus  digitorum.  The  first  pro- 
duces eversion  with  plantar  flexion,  the  others 
with  dorsal  flexion.  Thus  there  are  four  groups 
of  muscles  acting  on  the  subastragaloid  articula- 
tions which  balance  and  determine  the  movements 
of  the  foot,  and  four  positions  in  which  they  may 
fix  the  foot :  (1)  inversion  with  plantar  flexion 
(talipes  equino-varus) ;  (2)  eversion  with  plantar 


Chap.  XXIII]  ANKLE    AND    FOOT  579 

flexion  (talipes  equino-valgus) ;  (3)  inversion  with 
dorsi-flexion  (talipes  calcaneo-varus) ;  (4)  eversion 
with  dorsi-flexion  (talipes  calcaneo-valgus).  The 
position  assumed  will  depend  on  the  group  or 
groups  of  muscles  which  are  paralysed  or  weak- 
ened. Eversion  is  limited  by  the  inferior  calcaneo- 
scaphoid  ligament  and  the  structures  along  the 
inner  side  of  the  sole  of  the  foot— the  abductor 
hallucis,  plantar  fascia,  and  the  tibial  muscles. 
Inversion  is  limited  by  the  tuberosity  of  the 
scaphoid  coming  in  contact  with  the  sustenta- 
culum tali,  the  peroneal  muscles,  and  ligaments 
along  the  outer  border  of  the  foot.  The  move- 
ments of  inversion  and  eversion  correspond  to 
supination  and  pronation,  but  in  the  upper  ex- 
tremity these  are  produced  between  radius  and 
ulna,  whereas  in  the  lower  extremity  they  occur 
almost  entirely  between  the  astragalus  and  the 
rest  of  the  foot. 

Dislocation  of  the  astragalus. — This  bone 
is  sometimes  luxated  alone,  being  separated  from 
its  connections  with  the  os  calcis,  the  tibia,  the 
fibula,  and  the  scaphoid  bone*  The  displacement 
may  be  either  forwards,  backwards,  or  laterally. 
The  luxation  forwards  is  by  far  the  most  common 
lesion,  the  next  in  frequency  being  a  luxation 
outwards  and  forwards.  In  these  injuries  the 
interosseous  ligament  between  the  os  calcis  and 
astragalus  is  entirely  torn,  as  are  also  the  greater 
part  of  the  lateral  ligaments  of  the  ankle,  and 
the  various  bands  that  connect  the  astragalus  with 
the  os  calcis  and  scaphoid.  In  all  instances  the 
malleoli  are  brought  nearer  to  the  sole. 

Dislocation  of  the  os  calcis. — This  bone, 
although  often  fractured,  is  very  rarely  luxated. 
When  displaced,  however,  it^is  usually  displaced 
outwards,  and  is  torn  away  from  its  attachments 
to  the  astragalus  and  cuboid,  or  from  the  former 
bone  alone. 

Subastragaloid  dislocations  of  the  foot.— 
— In  these  lesions,  which  are  not  very  uncommon, 
the   astragalus   remains   in   position   between   the 


580  SUKGICAL    APPLIED    ANATOMY     [Part  V 

tibia  and  fibula,  while  the  rest  of  the  foot  is  dis- 
located below  that  bone.  The  luxation,  therefore, 
concerns  the  anterior  and  posterior  subastraga- 
loid  joints.  The  foot  may  be  displaced  either 
forwards,  backwards,  or  laterally.  The  forward 
dislocation  is  extremely  rare,  and  the  lateral  luxa- 
tions are  nearly  always  oblique.  In  the  most  usual 
displacements  the  foot  is  dislocated  outwards 
or  inwards,  and  is  at  the  same  time  carried  back- 
wards. These  luxations  are  often  compound, 
especially  when  lateral.  They  are,  as  a  rule, 
incomplete  as  regards  the  anterior  subastragaloid 
joint,  while,  on  the  other  hand,  the  displacement 
of  the  astragalus  from  the  scaphoid  is  in  nearly 
every  instance  complete.  In  all  cases  the  inter- 
osseous ligament  between  the  os  calcis  and  astraga- 
lus must  be  torn,  and  there  will  also  be  more 
or  less  laceration  of  the  ligaments  joining  the 
astragalus  to  the  scaphoid  and  to  the  malleoli. 
The  malleoli  are  very  often  fractured. 

It  is  only  necessary  to  notice  in  any  detail  the 
two  lateral  luxations,  as  being  the  only  common 
forms.  In  the  inward  dislocation  the  foot  is  in- 
verted, its  inner  border  is  raised,  is  shortened, 
and  rendered  concave,  while  its  outer  border  is 
lengthened  and  made  convex.  The  deformity 
much  resembles  that  of  talipes  varus.  The  head 
of  the  astragalus  with  the  outer  malleolus  forms 
a  projection  at  the  outer  aspect  of  the  foot,  while 
below  them  a  deep  hollow  exists.  The  inner 
border  of  the  os  calcis  is  very  prominent  at  the 
internal  side  of  the  limb,  while  the  inner  malleolus 
is  buried  in  the  hollow  left  by  the  displacement  of 
that  bone.  The  calcaneum  and  scaphoid  are  ap- 
proximated. In  the  outward  luxation  the  foot 
is  abducted,  its  outer  border  is  raised,  and  the 
deformity  produced  is  not  unlike  that  of  talipes 
valgus.  The  outer  malleolus  is  lost  in  the  hollow 
caused  by  the  eversion  of  the  foot,  while  the  tibial 
malleolus  and  head  of  the  astragalus  form  a  pro- 
jection on  the  inner  aspect  of  the  limb. 

The    inediotarsal  joint    is  situated  between 


Chap.  XXIII]  ANKLE    AND    FOOtf  58l 

the  head  of  the  astragalus  and  scaphoid  on  the 
inner  side  of  the  foot,  and  os  calcis  and  cuboid  on 
the  outer.  The  inner  is  part  of  the  anterior  sub- 
astragaloid  joint  (see  p.  578),  while  the  outer  has 
a  separate  synovial  cavity.  It  should  be  noted 
that  the  movements  of  turning  the  toes  either 
in  or  out  take  place  mainly  at  the  hip-joint; 
while  the  turning  of  one  edge  of  the  foot  either 
up  or  down  is  a  movement  that  mostly  concerns 
the  subastragaloid  joints. 

Club-foot.  —  It  is  usual  to  divide  the  various 
forms  of  talipes,  or  club-foot,  into  four  main 
divisions,  viz.  (1)  T.  equinus;  (2)  T.  calcaneus; 
(3)  T.  varus;  and  (4)  T.  valgus.  Four  secondary 
forms  result  from  combinations  of  these  principal 
varieties,  viz.  T.  equino-varus,  T.  equino-valgus, 
T.  calcaneo-varus,  and  T.  calcaneo-valgus,  corre- 
sponding to  the  four  positions  assumed  by  the  foot 
at  the  subastragaloid  articulations  (see  p.  578). 

1.  Talipes  equinus.  In  this  deformity  the  heel 
is  drawn  up,  and  the  patient  walks  upon  the  balls 
of  the  toes.  The  contracting  muscles  are  those  of 
the  calf  attached  to  the  tendo  Achillis.  There  is 
flexion  of  the  ankle  and  marked  inversion  of  the 
foot.  In  a  well-marked  case  the  os  calcis  is 
much  raised,  and  may  even  be  brought  in  contact 
with  the  tibia.  The  astragalus  is  displaced  down- 
wards, and  projects  upon  the  dorsum.  The  foot 
tends  to  become  more  and  more  inverted,  until 
at  last  the  scaphoid  may  even  touch  the  sustenta- 
culum. The  ligaments  of  the  sole  are  usually 
much  contracted. 

2.  Talipes  calcaneus.  In  this  form  of  club-foot 
the  toes  are  drawn  up,  and  the  patient  walks  upon 
the  heel.  The  contracting  muscles  are  the  ex- 
tensors on  the  anterior  aspect  of  the  limb.  The 
os  calcis  is  rendered  more  vertical,  and  the 
astragalus  becomes  so  obliquely  placed  that  part 
of  its  upper  articular  surface  may  project  beyond 
the  tibia  in  a  backward  direction. 

3.  Talipes  varus.  This  is  the  commonest  form. 
Certain   features  of  the   fcetal   foot  are   retained 


532  SURGICAL   APPLIED   ANATOMY     [Part  V 

in  an  exaggerated  degree.  In  a  well-marked  con- 
genital case  there  is  a  threefold  deformity  :  (1) 
The  heel  is  drawn  up  by  the  muscles  attached  to 
the  tendo  Achillis ;  (2)  the  foot  is  inverted  by  the 
contraction  of  the  tibialis  anticus  and  posticus; 
(3)  the  sole  is  contracted  by  the  flexor  longus 
digitorum  muscle  and  the  shrinking  of  the  plantar 
fascia  and  ligaments.  The  neck  of  the  astragalus 
is  elongated  and  deflected  downwards  and  inwards 
to  a  greater  extent  than  in  the  normal  foot.  In 
the  adult  the  neck  of  the  astragalus  is  deflected 
inwards  to  the  axis  of  its  body  at  an  angle  of  10° ; 
in  the  newly  born  at  an  angle  of  25°  ;>  and  jn 
talipes  varus  at  an  angle  of  50°.  The  scaphoid 
is  displaced  upwards  and  inwards,  until  its 
inner  border  often  touches  the  internal  malleolus. 
The  three  cuneiform  bones  follow  the  scaphoid, 
and  the  cuboid  becomes  the  lowest  bone  in  the 
tarsus.  The  outer  border  of  the  cuboid  forms  an 
angle  with  the  os  calcis,  and  the  tendons  of  the 
peroneus  longus  slip  backwards  from  the  groove 
in  the  cuboid  to  lie  on  the  os  calcis.  The  anterior 
border  of  the  internal  lateral  ligament  is  con- 
tracted and  unduly  prominent.  There  is  thus  a 
marked  degree  of  inversion. 

4.  In  talipes  valgus  the  foot  assumes  perma- 
nently the  position  of  eversion.  The  contracting 
muscles  are  the  two  peronei.  In  a  well-marked 
congenital  case  the  os  calcis  is  found  a  little 
raised  and  the  astragalus  is  displaced  forwards 
and  downwards.  The  scaphoid  is  so  rotated  that 
its  inner  part  is  depressed  and  its  outer  raised. 
The  internal  portion  of  the  bone  forms  one  of 
the  two  projections  obvious  on  the  inner  side  of 
the  foot,  the  other  prominence  being  formed  by 
the  head  of  the  astragalus.  The  cuboid  is  found 
to  be  a  little  rotated  outwards.  The  arch  of  the 
foot  is  lost,  and  all  those  ligaments  are  stretched 
that  serve  to  support  and  maintain  that  arch. 

Of  the  mixed,  or  secondary,  forms  of  talipes 
nothing  need  be  said.  They  are  the  results  merely 
of  a  combination  of  the  primary  varieties. 


Chap.  XXIII] 


ANKLE    AND    FOOT 


583 


As  trouble  is  often  caused  in  talipes  by  pres- 
sure being  brought  to  bear  upon  an  unusual  part 
of  the  foot,  it  is  well  to  note  upon  what  portion 
of  the  member  the  patient  treads  in  the  different 
varieties  of  the  deformity.  In  varus  the  "tread  " 
is  mainly  upon  the  outer  side  of  the  fifth  meta- 
tarsal bone ;  in  valgus  upon  the  internal  malleolus 
and  scaphoid ;  in  equinus  upon  the  bases  of  all 
the  toes;  in  equino-varus  upon  the  base  of  the 
little  toe ;  in  equino-valgus  upon  the  base  of  the 
great  toe;  in  all  forms  of  calcaneus  upon  the 
heel.  In  cases  of  extreme  and  obstinate  club-foot 
wedges  of  bone  are  sometimes  removed  bv  the 
operation  known  as  tarsectomy.  Thus  in  talipes 
equino-varus  the  base  of  the  wedge  will  be  on  the 
outer  side  of  the  foot,  and  will  be  mainly  repre- 
sented by  the  cuboid;  the  apex  will  be  at  the 
scaphoid. 

Flat  -  foot  and  splay  -  foot  are  the  names 
given  to  a  deformity  due  probably  to  the  yield- 
ing of  certain  ligaments,  whereby  the  arch  of  the 


/lEAD   OpASTRACALUS 

Inf.  CALCA/ieo-ScAP/1  Liq. 
Tuberosity  ofScap/ioid 

Fig.  97. — Dissection  of  a  flat-foot  from  the  inner  side. 


DO  ACrtlLLl  s 

.L.Dicitorum 
t.  Malleolus 
ibialis  Post. 

SuSTEflT.TALI 


foot  is  lost  and  the  sole  becomes  more  or  less 
perfectly  flat.  The  foot,  at  the  same  time,  is  ab- 
ducted, and  the  outer  border  is  often  a  little 
raised,    so   that  the   patient   walks   mainly   upon 


584  SUEGICAL   APPLIED    ANATOMY      [Part  V 

the  inner  side  of  the  foot.  This  deformity  is  met 
with  in  those  who  stand  a  great  deal,  and  is  the 
direct  result  of  yielding  of  the  muscles  which 
maintain  the  foot  in  a  position  of  inversion — 
especially  the  tibialis  anticus  and  posticus.  It 
is  only  when  these  muscles  become  exhausted  and 
yield  that  the  ligaments  are  strained  and  elon- 
gated, for  it  may  be  accepted  as  a  lav/  that  the 
normal  strain  at  a  joint  falls  on  the  muscles,  the 
ligaments  only  coming  into  action  in  limiting  the 
extent  of  movements.  The  inferior  calcaneo- 
scaphoid  ligament  is  lax  in  the  standing  posture ; 
the  weight  of  the  head  of  the  astragalus  is  then 
supported  by  the  tibialis  posticus  (Fig.  97). 

As  is  well  known,  the  muscles  of  the  leg  and 
foot  become  more  quickly  exhausted  when  stand- 
ing than  when  walking,  for  in  the  standing 
posture  the  muscles  which  invert  the  foot  are 
maintained  in  a  condition  of  tonus,  whereas  in 
walking  they  have  alternate  periods  of  action  and 
rest.  Hence  in  those  whose  occupations  entail 
prolonged  periods  of  standing,  the  muscles  which 
maintain  the  inversion  of  the  foot  become  ex- 
hausted— especially  the  tibialis  posticus;  they 
gradually  yield,  and  the  superincumbent  weight 
of  the  body  then  falls  on  the  structures  which 
limit  eversion  of  the  foot,  especially  the  inferior 
calcaneo-scaphoid  ligament,  on  which  the  head  of 
the  astragalus  then  comes  to  rest  (Fig.  97).  When 
the  weight  falls  on  this  ligament  it  begins  to 
yield;  the  head  of  the  astragalus  is  pressed  for- 
wards, downwards,  and  inwards  by  the  superin- 
cumbent weight,  and  the  foot  beyond  becomes,  as 
a  consequence,  over-extended  and  turned  out  (Fig. 
97).  The  os  calcis  slants  inwards,  and  its  anterior 
end  is  depressed.  The  sustentaculum  tali,  the 
head  of  the  astragalus,  and  the  scaphoid  tubercle 
form  prominences  on  the  inner^  side  of  the  foot, 
and  may  rest  on  the  ground  (Fig.  97).  The  long 
and  short  plantar  ligaments  also,  which  contribute 
so  much  to  the  maintenance  of  the  arch  of  the 
foot,   in  time  yield,   and  allow  of  a  still  greater 


Chap.  XXIII] 


ANKLE    AND    FOOT 


595- 


degree  of  deformity.  There  is  a  stretching  also 
of  the  deltoid  ligament.  In  neglected  cases  the 
distortion  is  rendered  more  or  less  permanent  by 
alterations  in  the  shape  of  the  tarsal  bones,  and  by 
a  contraction  of  such  ligaments  as  have  been  re- 
laxed by  the  deformity.  The  scaphoid  and  inter- 
nal cuneiform  become  markedly  wedge-shaped, 
with  the  apices  directed  on  the  dorsum  of  the  foot 


Fig.  98. — Various  forms  of  foot-prints. 
A,  Of  normal  foot  with  high  arch ; 


c, 


Hat  foot. 


also  with  high  arch 
with  low  arch  :  ; 


(Fig.  97).  The  foot  being  abducted,  and  its  outer 
border  a  little  raised,  the  peronei  muscles  become 
relaxed,  shortened,  and  contribute  to  the  perma- 
nency of  the  disorder.  It  will  be  understood  that 
the  abnormal  pressure  brought  to  bear  upon  the, 
various  tarsal  bones  and  articulations  will  cause 
severe  pain  to  be  often  associated  with  this  affec- 
tion. The  calf  muscles  waste,  owing  to  the  arch 
of  the  foot  having  lost  its  rigidity  and  being  no 
longer  able  to  support  the  weight  of  the  body. 
Imprints  of  normal   feet  vary  much  in   form 


586  SURGICAL   APPLIED    ANATOMY     [Part  V 

{see  Fig.  98).  Dr.  Lovett,  of  Boston,  is  of  opinion 
that  the  feet  which  come  in  contact  with  the 
ground  at  only  two  parts — at  the  heel  behind 
and  along  the  pad  of  the  foot  in  front — are  those 
which  are  most  prone  to  break  down  (Fig.  98,  a). 
In  flat  foot  the  inner  border  of  the  foot  also  comes 
in  contact  with  the  ground,  so  that  the  area  be- 
tween the  heel,  the  plantar  pad,  and  the  outer 
margin  of  the  foot,  left  blank  in  the  normal  im- 
print, becomes  partially  or  completely  filled  up 
(Fig.  98). 

It  may  be  noted  that  the  medio-tarsal  joint, 
which  is  so  conspicuously  involved  in  the  distor- 
tion, is  supplied  by  the  anterior  tibial,  musculo- 
cutaneous,  and  external  plantar  nerves. 

The  tarsal  bones,  owing  to  their  spongy 
character,  are  readily  broken  by  direct  violence, 
as  in  severe  crushes.  The  soft  parts  that  cover 
these  bones  being  scanty  upon  the  dorsal  aspect 
of  the  foot,  it  follows  that  these  accidents  are 
often  compound  and  associated  with  much  lacera- 
tion of  the  integuments. 

The  tarsal  bone  the  most  frequently  fractured 
is  the  os  calcis.  This  bone  may  be  broken  by  a 
fall  upon  the  heel,  and  in  many  instances  has 
been  the  only  one  fractured  by  such  an  accident. 
A  few  cases  have  been  recorded  of  fracture  of 
the  calcaneum  by  muscular  violence,  the  muscles 
producing  the  lesion  being  those  attached  to  the 
tendo  Achillis.  Thus,  Sir  A.  Cooper  reports  the 
case  of  a  woman,  aged  forty-two,  in  whom  a 
large  fragment  of  the  posterior  part  of  the  os 
calcis  was  torn  away  by  the  muscles  and  drawn 
some  2\  inches  away  from  the  heel.  The  accident 
was  caused  by  her  taking  a  false  step.  Abel  has 
collected  three  cases  of  fracture  of  the  sustentac- 
ulum tali.  He  believes  that  this  injury  may  be 
produced  by  falls  upon  the  sole  or  by  extreme  in- 
version of  the  foot,  whereby  the  astragalus  is 
forced  violently  against  the  process. 

The  astragalus  alone  may  be  broken  by  a  fall 
upon  the  feet,  and  such  accidents  are  often  associ- 


Chap.  XXtll]  ANKLE    AND    FOOT  587 

ated  with  fractures  of  both  that  bone  and  the  os 
calcis.  It  must  be  noted,  however,  that  in  a  fall, 
when  the  patient  alights  upon  the  feet,  the  tibia 
and  fibula  are  much  more  likely  to  be  broken  than 
are  the  tarsal  bones,  since  the  bones  of  the  leg 
transmit  the  weight  of  the  body  directly,  whereas 
that  weight  is  much  diffused  and  broken  up  when 
passing  through  the  foot  with  its  many  bones  and 
joints. 

The  metatarsal  bones  and  phalanges  are  nearly 
always  broken  by  direct  violence.  I  had,  how- 
ever, under  my  care  at  the  London  Hospital  a 
man  who  had  broken  the  shafts  of  the  three  outer 
metatarsal  bones  by  simply  slipping  off  the  edge 
of  the  curb.  Since  the  introduction  of  X-rays  as 
a  means  of  diagnosis,  fractures  of  the  metatarsal 
bones,  especially  of  the  fifth,  and  of  the  phalanges, 
are  found  to  occur  not  infrequently,  and  often  as 
the  result  of  a  movement  or  accident  which  seems 
totally  insufficient  to  produce  such  lesions. 

With  regard  to  the  luxations  of  the  foot  not 
yet  considered,  it  may  be  said  that  the  cuboid 
is  never  dislocated  alone.  Walker  reports  a  case 
of  dislocation  of  the  scaphoid  alone,  that  structure 
being  quite  separated  from  the  astragalus  and 
cuneiform  bones.  The  accident  was  brought  about 
by  alighting  upon  the  ball  of  the  foot  when  jump- 
ing, and  the  little  bone  was  found  projecting  on 
the  dorsum.  Mr.  Bryant  has  mentioned  an  in- 
stance of  dislocation  of  the  scaphoid  inwards. 
As  a  rule,  however,  this  bone  when  displaced  is 
dislocated  along  with  the  astragalus. 

Of  the  cuneiform  bones  the  one  most  often 
luxated  alone  is  the  internal.  The  attachments 
of  the  tendons  of  the  tibialis  anticus  and  peroneus 
longus  about  the  internal  cuneiform  and  first 
metatarsal  bones  render  it  common  for  the  latter 
to  follow  its  tarsal  colleague  when  dislocated. 
Mr.  Luke  has  recorded  a  case  of  incomplete  luxa- 
tion of  all  three  cuneiform  bones  upwards,  and 
at  least  three  cases  have  been  described  of  disloca- 
tion of  the  internal  bone  upwards  and  backwards, 


588  SURGICAL   APPLIED    ANATOMY     [Part  V 

together  with  a  like  displacement  of  all  the  meta- 
tarsals. 

One  or  more  of  the  metatarsal  bones  may  be 
luxated,  or  the  entire  series  may  be  displaced 
upwards,  downwards,  inwards,  or  outwards,  the 
first-named  lesion  being  the  most  common.  In 
rarer  instances,  one  bone  has  been  thrown  in  one 
direction  and  its  fellow  or  fellows  in  another. 

Ossification  of  the  tarsus. — At  birth  the 
tarsus  is  mainly  cartilaginous.  Ossification  be- 
gins in  the  os  calcis  in  the  sixth  month  and  in 
the  astragalus  in  the  seventh  month  of  foetal  life. 
The  centre  for  the  cuboid  appears  at  birth,  and 
in  the  scaphoid,  the  last  to  ossify,  in  the  third 
year.  It  is  not  until  puberty  that  the  cartilage 
of  the  tarsal  bones  is  completely  ossified.  Like  the 
epiphyses  of  long  bones  the  tarsal  bones  are  en- 
tirely formed  in  cartilage,  there  being  no  peri- 
osteal formation.  Hence  it  is  possible,  as  Ogston 
has  shown,  to  enucleate  the  ossific  centres  from  the 
tarsal  bones  of  children  who  are  the  subjects  of 
club-foot  and  by  remodelling  the  cartilaginous 
capsules  left  behind,  obtain  new  ossifications  of 
a  more  normal  form. 

Dislocation  of  the  proximal  phalanx  of  the 
great  toe  is  often  very  difficult  to  reduce,  as  is 
also  the  case  in  the  corresponding  luxation  of  the 
thumb.  When  the  displacement  is  dorsal,  the 
difficulty  is  probably  due  to  the  sesamoid  bones, 
which  are  embedded  in  the  glenoid  ligament  or 
fibro-cartilaginous  plate.  "  Like  the  glenoid  liga- 
ments, the  sesamoid  bones  are  much  more  firmly 
connected  with  the  phalanx  than  with  the  meta- 
tarsal bone,  and  thus  get  torn  away  and  shut 
back  behind  the  head  of  the  metatarsal  bone ;  or 
it  may  be  that  the  sesamoid  bones,  retaining  their 
connections  with  the  lateral  ligaments  of  the  joint 
as  well  as  with  the  short  flexor  tendons,  are 
separated  from  one  another,  and  so  allow  the 
head  of  the  metatarsal  bone  to  pass  forwards, 
and  thus  become  nipped,  as  it  were,  in  a  button- 
hole between  them  "   (Henry  Morris).     A  partial 


Chap.  XXIII] 


ANKLE    AND    FOOT 


589 


dislocation  of  the 
proximal  phalanx 
outwards  on  the  head 
of  the  metatarsal 
bone  of  the  great  toe 
constitutes  the  con- 
dition known  as 
hallux  valgus.  The 
inner  lateral  liga- 
ment of  the  joint  is 
elongated,  while  the 
outer  is  contracted. 
In  hallux  rigidus 
this  joint  is  slightly 
flexed  and  rigid,  due 
probably  to  a  reflex 
contraction  of  the 
flexor  brevis  hallucis. 
The  second  toe  is  com- 
monly longer  than 
the  others,  and  is 
more  liable  to  assume 
the  form  known  as 
"  hammer  toe."  The 
proximal  phalanx  in 
such  a  form  is  ex- 
tended, while  the 
middle  is  strongly 
flexed.  The  condition 
is  commonly  inherit- 
ed, and  is  due  to  a 
contraction  of  the 
glenoid  and  lateral 
ligaments  of  the 
proximal  phalangeal 
joint.  The  extensor 
tendon  is  also  con- 
tracted. 

There       are       six 
synovial      cavities 
in   the    foot,    excluding 
viz.    one   for   the   poster 


Fig.    99.  —  Oblique    anteroposterior 
section  of  the  foot.    (Eudingcr.) 

],  Tibia  ;  2,  fibula  ;  3,  astragalus  ;  4,  os 
oalcis  ;  5,  external  lateral  ligament  ; 
tj,  internal  lateral  ligament ;  7,  inter- 
osseous ligament  between  astragalus 
and  os  calcis ;  8,  head  of  astragalus; 
9,  scaphoid  ;  10,  11  and  12,  the  three 
cuneiform  bones;  13,  cuboid. 


that   of   the    ankle-joint, 
ior   subastragaloid   joint. 


590 


SURGICAL   APPLIED    ANATOMY      [Part  V 


a  second  for  the  anterior  subastragaloid,  a  third 
between  the  os  calcis  and  cuboid,  a  fourth  between 
the  latter  bone  and  the  two  outer  metatarsals,  a 
fifth  for  the  joint  between  the  inner  cuneiform  and 
first  metatarsal  bones,  and  a  sixth  for  the  remain- 
ing articulations  (Fig.  99).  These  synovial  cavities 
tend  greatly  to  diffuse  disease  among  the  various 
bones  of  the  foot  when  once  one  bone  has  become 


Fig.  100.— Syme's  amputation.    (Agatz.) 

Tibia  •  b,  fibula  ;  c,  tibialis  anticus  ;  d,  extensor  proprius  pollicis  ;  e,  extensor 
communis  digitorum  ;/,  peroneus  tertius;  g,  flexor  longus  pollicis;  //.tibialis 
posticus;  i  flexor  longus  digitorum;  ;",  peroneus  brcvis ;  7;,  peroneus  longus ; 
I  tendo  Achillis :  m,  some  muscles  of  the  sole  that  are  not  usually  left  in  this 
operation  ;  n,  anterior  tibial  vessels;  o,  posterior  tibial  vessels  ;  p,  posterior 
tibial  nerve. 


Chap.  XXIII]  ANKLE    AND    FOOT  591 

inflamed.  The  best  position,  therefore,  for  bone 
disease,  with  reference  to  the  question  of  exten- 
sion, would  be  in  the  hinder  parts  of  either  the 
os  calcis  or  astragalus,  and  one  of  the  worst  posi- 
•  tions  would  be  assumed  by  disease  involving  the 
scaphoid  bone. 

Myiue's  amputation  at  the  ankle. — In  the 
heel-flap  are  cut  the  integuments,  the  external 
saphenous  nerve  and  vein,  the  peroneus  longus, 
peroneus  brevis,  tibialis  posticus,  flexor  longus 
digitorum,  flexor  longus  hallucis,  tendo  Achillis, 
points  of  origin  of  the  flexor  brevis  digitorum 
and  of  the  two  abductor  muscles,  and  the  internal 
and  external  plantar  arteries  and  nerves. 

In  the  dorsal  flap  are  cut  the  integuments, 
tibialis  anticus,  extensor  communis  digitorum,  ex- 
tensor proprius  hallucis,  peroneus  tertius,  anterior 
tibial  vessels  and  nerve,  musculo-cutaneous  nerve, 
and  internal  saphenous  nerve  and  vein.  The  posi- 
tion of  the  principal  structures  divided  is  shown 
in  Fig.  100.  It  is  not  usual  to  dissect  up  any  of 
the  muscular  tissue  of  the  sole,  as  shown  in  Agatz's 
plate.  It  should  be  noted  that  the  integuments 
of  the  heel  derive  their  blood  supply,  which  is 
very  free,  mainly  from  the  external  calcaneal 
branch  of  the  posterior  peroneal  artery,  and  the 
internal  calcaneal  from  the  external  plantar. 

If  the  heel  incision  is  carried  sufficiently  far 
back  to  divide  the  trunk  of  the  posterior  tibial 
artery,  the  heel  flap  is  deprived  of  the  last-named 
source  of  blood  supply.  The  posterior  tibial 
artery  bifurcates  upon  a  line  drawn  from  the  tip 
of  the  inner  malleolus  to  the  centre  of  the  con- 
vexity of  the  heel. 

The  nerves  supplying  the  integuments  of  the 
heel  are  the  calcaneal  branch  of  the  external 
saphenous  and  the  calcaneal  and  plantar  cutane- 
ous twigs  from  the  posterior  tibial. 

In  Pirog-off's  amputation  the  parts  divided 
in  the  anterior  flap  are  the  same  as  in  Syme's 
operation.  In  the  heel  or  sole  flap  the  same 
structures  also   are  cut  as  in   the   corresponding 


592 


SURGICAL   APPLIED    ANATOMY     [Part  V 


flap  in  a  Syme,  with  the  exception  that  the 
tendo  Achillis  is  not  divided,  the  flexor  brevis 
digitorum,  abductor  pollicis,  abductor  minimi 
digiti,  and  flexor  accessorius  are  divided  more  ex- 
tensively, and  the  plantar  vessels  are  cut  farther 
from  the  bifurcation. 

Cliopart's  operation  is  an  amputation  at 
the  mediotarsal  joint.  In  the  dorsal  flap  are  cut 
the  integuments,  the  extensor  communis  and  brevis 

digitorum,  ex- 
tensor proprius 
hallucis,  tibialis 
anticus,  pero- 
neus  tertius  and 
brevis,  the  mus- 
culo -  cutaneous, 
anterior  tibial, 
and  two  saphen- 
ous nerves,  the 
dorsal  artery, 
and  the  dorsal 
plexus  of  veins. 
In  the  plantar 
flap  are  found 
divided  the  in- 
teguments, plan- 
tar fascia,  flexor 
brevis  digitor- 
um, abductors 
of  the  great  and 
little  toes,  flexor 
accessorius,  and 
tibialis  posticus 
tendon.  If  the 
flap  be  well  dis- 
sected up  from 
the  bones,  parts  of  the  short  flexors  of  the  great 
and  little  toes,  the  abductor  hallucis,  and  trans- 
versus  pedis  will  be  found  cut  in  the  flap.  The 
tendons  of  the  long  flexors  of  the  digits  and  great 
toes,  the  peroneus  longus,  and  the  plantar  vessels 
and  nerves  are  also  divided  (Fig.  101). 


Chopart's  operation.    (Agatz.) 


Astragalus  ;   b,  os  calcis  ;   c,  extensor  proprius 
hallucis  ;  d,  tibialis   anticus  ;  e,  extensor  com- 
munis digitorum  ;  /,  peroneus  longus ;  g,  abduc- 
tor minimi  digiti;  h,  flexor  brevis  digitorum 
•i,  flexor  longus  dig'torum  ;  j,  abductor  hallucis 
ft,  flexus  longus  hallucis  ;  1,  dorsalis  pedis  artery 
m,  internal  plantar  artery  ;  n,  external  plantar 
artery. 


Chap.  XXIII] 


ANKLE    AND    FOOT 


593 


Lisfranc's  operation,  or  amputation  through 
the  tarso-metatarsal  line  of  joints  (Fig.  102).     In 
the    dorsal    flap    the 
same    structures    are 
divided  as  are  cut  in 
the         corresponding 
flap      in      Chopart's 
amputation.      In   the 
plantar  flap  also  the 
parts      divided      are 
the   same   as  in  that 
procedure,    with    the 
exception     that     the 
flexor      accessorius 
and    the    tendon    of 
the    tibialis    posticus 
escape    section.      The 
articulations      be- 
tween the  three  outer 
metatarsals    and   the 
corresponding   tarsal 
bones     form     a     line 
sufficiently      straight 
to    be    traversed    by 
the  knife  in  one  cut 
when  once  the  blade 
has  been  introduced. 
The   joint   also   be- 
tween the  first  meta- 
tarsal   and    internal 
cuneiform  bones  is  in 
a    straight    line    and 
readily  opened.     The 
most  difficult  part  of 

the  disarticulation  concerns  the  separation  of  the 
second  metatarsal  bone,  which  is  deeply  lodged 
between  the  tarsal  segments.  The  chief  bond  of 
union  between  this  bone  and  the  tarsus  is  effected 
by  a  strong  interosseous  ligament  that  passes  be- 
tween it  and  the  internal  cuneiform.  In  Fig.  102 
the  knife  is  placed  in  the  position  required  to 
divide  that  ligament, 
2  m 


Fig.  102. — Lisfranc's  operation.  (Agatz. 

a,  b,  c.  Inner,  middle,  and  outer  cuneiform 
bones  ;  il,  cuboid  ;  e,  f,  the  metatarsal 
bones;  g,  tibialis  anticus ;  h,  extensor 
proprius  hallucis  ;  i,  extensor  communis 
djgitoruin  ;  j,  extensor  brevis  digi- 
torum ;  fc,  extensor  tendons;  I,  dorsalis 
pedis  artery. 


594 


SURGICAL    APPLIED    ANATOMY     [Part  V 


In  the  subastragaloid  amputations  a  dis- 
articulation is  effected  at  the  subastragaloid 
articulations.  The  astragalus  is  the  only  bone  of 
the  foot  left  behind,  and  forms  the  summit  of  the 
stump. 

Fig.  103  shows  the  position  of  the  more  im- 
portant structures  that  are  divided  in  amputation 
of  the  great  toe  together  with  its  metatarsal  bone. 

The  nerve  supply  of  the  lower  limb.— In 
Fig.   104  is  shown  the  cutaneous  nerve-supply  of 


Fig.  103. — Amputation  of  great  toe,  with  its  metatarsal  bone.     (Agatz.) 

a,  Internal  cuneiform  bone  ;  b,  adductor  liallucis  ;  c,  extensor  longus  hallucis  ; 
d,  flexor  longus  liallucis ;  e,  plantar  branch  of  dorsalis  pedis  artery. 

the  inferior  extremities  on  both  the  anterior  and 
the  posterior  aspect,  and  in  Fig.  105  are  seen  the 
cord  segments  from  which  they  are  derived. 
Paralyses  of  the  lower  limbs  are  common,  but  are 
more  often  due  to  some  lesion  in  the  inferior 
segment  of  the  cord  than  to  damage  received  by 
any  one  individual  nerve.  Cases,  however,  are 
recorded  where  a  single  trunk  has  been  injured 
and  a  limited  form  of  paralysis  has  followed  in 
consequence. 

Paralysis  of  the  anterior  crural  nerve 
has  been  caused  by  injuries  to  the  lower  part  of 
the     vertebral     column     implicating     the     cauda 


t- 


8 


\  i  S 


1*1    8 


Fig.    104.  —  Cutaneous 

uerve-supply  of  lower 

limli. 
11 

aspect.— 1,  Ilioinguinal ;  2,  genito-crural ;  3,  external  cutaneous :  4,  middle 
cutaneous;  •",,  internal  cutaneous;  6,  patellar  plexus:  7,  branches  <>f  external 
popliteal;  8,  internal  saphenous;  9,  tnusculo-cutaneous ;  ID,  external  saphe- 
nous; 11,  anterior  tibial. 
Posterior  aspect.— 1,  2,  and  ■".,  small  sciatic;  4,  external  cutaneous;  5,  internal 
cutaneous;  6,  internal  saphenous;  7,  branches  of  external  popliteal;  8,  short 
saphenous;!i,  posterior  tibial;  10,  internal  saphenous;  11,'  internal  plantar; 
12,  external  plantar. 


596  SUKGICAL    APPLIED    ANATOMY      [Part  V 

equina,  by  fractures  of  the  pelvis,  by  tumours  of 
the  pelvis,  by  psoas  abscess,  by  fractures  and  dis- 
locations of  the  femur,  and  by  stabs  in  the  region 
of  the  groin.  In  this  nerve  lesion  the  patient  is 
unable  to  flex  the  hip  or  to  raise  the  body  from 
the  recumbent  position  (ilio-psoas).  The  adductor 
muscles  may  simulate  the  action  of  the  flexors 
of  the  hip,  but  it  will  be  observed  that  they  rotate 
and  adduct  the  thigh  as  well  as  flex  it.  The  power 
of  extending  the  leg  at  the  knee  is  lost  (quadri- 
ceps extensor  cruris) ;  the  function  of  the  sar- 
torius  is  destroyed  and  that  of  the  pectineus  im- 
paired. Sensation  is  impaired  in  parts  supplied 
by  the  internal  and  middle  cutaneous  nerves  and 
the  long  saphenous  nerve. 

Paralysis  of  the  obturator  nerve  alone  is 
a  rare  condition,  although  it  may  be  found  associ- 
ated with  a  like  lesion  of  the  preceding  trunk. 
It  may  be  brought  about  by  the  pressure  exer- 
cised upon  the  nerve  in  cases  of  obturator  hernia 
and  by  the  foetal  head  during  delivery.  The 
muscles  implicated  are  the  adductors,  gracilis, 
and  external  obturator.  The  patient  is  unable  to 
press  the  knees  together,  or  to  cross  the  legs. 
Rotation  outwards  is  difficult,  but  sensation  is 
scarcely  affected  in  the  skin  supplied. 

Paralysis  of  the  internal  popliteal  nerve. 
— There  is  inability  to  flex  the  ankle  and  to  flex 
the  toes  (flexor  longus  digitorum,  flexor  proprius 
hallucis,  tibialis  posticus,  gastrocnemius,  and 
soleus).  The  patient  is  unable  to  stand  upon  the 
toes,  owing  to  loss  of  function  in  the  two  last- 
named  muscles.  The  power  of  inverting  the  foot 
is  impaired  (tibialis  posticus),  and  lateral  move- 
ment in  the  toes  is  lost  owing  to  paralysis  of  all 
the  small  muscles  of  the  sole.  Sensation  is  im- 
paired over  the  plantar  aspect  of  the  toes,  the 
sole,  and  in  part  of  the  lower  half  of  the  back 
of  the  leg. 

In  paralysis  of  the  external  popliteal  nerve 
the  action  of  the  muscles  on  the  front  of  the  leg  is 
lost.     The  foot  hangs  down  and  the  toes  catch  the 


Fig.  105. — Showing  the  skin  areas  in  the  lower  extremity  supplied  by 
the  lumbar  and  sacral  segments  of  the  spinal  cord.     {After  Head.) 

i  in    each   area  is  indicated  the  segment  of   the-   cord  by  which  it   is  supplied 
Fur  the  nerves  supplying  each  area  see  Fig.  104 


598  SUKGICAL   APPLIED   ANATOMY     [Part  V 

ground  in  walking.  The  foot  can  be  neither  dorsi- 
flexed  nor  everted  (extensor  communis  digitorum, 
extensor  proprius  hallucis,  peroneal  muscles). 
Adduction  is  imperfect,  owing  to  paralysis  of 
the  tibialis  anticus.  Extension  of  the  toes  is 
only  possible  to  the  slight  extent  effected  by  the 
interossei.  The  arch  of  the  foot  becomes  flattened 
owing  to  loss  of  the  support  furnished  by  the 
peroneus  longus.  Sensation  is  impaired  over  the 
front  and  outer  side  of  the  leg  and  on  the  dorsum 
of  the  foot,  and  also  over  some  part  of  the  back  of 
the  leg,  owing  to  paralysis  of  the  communicans 
peronei. 

The  fibres  destined  for  any  particular  muscle 
are  not  assorted  in  one  fasciculus  until  near  their 
point  of  exit  from  the  nerve  trunk ;  hence  a  nerve 
trunk  such  as  the  internal  popliteal  may  be  partly 
divided  without  any  apparent  effect.  This  cir- 
cumstance is  taken  advantage  of  in  cases  of  in- 
fantile paralysis.  In  a  case  where  the  external 
popliteal  is  affected,  action  of  the  extensor  muscles 
may  be  restored  by  suturing  that  nerve  to  a  slip 
partially  separated  from  the  internal  popliteal. 

When  the  great  sciatic  nerve  is  paralysed 
there  will  be,  in  addition  to  the  loss  of  function 
in  the  two  preceding  nerves,  an  inability  to  flex 
the  knee  owing  to  paralysis  of  the  hamstrings, 
while  rotation  of  the  limb  may  be  impaired  by 
loss  of  power  in  the  quadratus  femoris  and  ob- 
turator internus.  Mr.  Sherren  found  that  the 
knee  may  still  be  flexed  in  such  cases  through  the 
action  of  the  gracilis,  and  that  sensation  was  com- 
pletely lost  in  only  part  of  the  sole  of  the  foot. 

A  knowledge  of  the  segments  of  tlic  cord 
from  whicli  the  nerves  of  the  lower  limb 
arise  often  assists  the  surgeon  in  localising  cer- 
tain lesions.  Section  of  a  nerve  root,  as  may 
happen  in  fracture  of  the  spine,  or  destruction 
of  its  centre  in  the  spinal  cord,  gives  rise  to 
paralysis  in  a  definite  group  of  muscles  and 
anaesthesia  of  a  certain  area  of  skin.  The  skin 
areas  supplied  by  the  lumbar  and  sacral  segments 


Chap.  XXIII]  ANKLE    AND    FOOT  599 

are  shown  in  Fig.  105,  and  these  segments,  accord- 
ing to  Kocher,  innervate  the  following  groups  of 
muscles  :  Third  lumbar,  the  psoas,  iliacus,  pec- 
tineus,  sartorius  and  adductors;  fourth  lumbar, 
quadriceps  extensor  cruris;  fifth  lumbar,  gluteus 
medius  and  minimus,  tensor  vaginae  femoris  and 
hamstrings;  first  sacral,  gluteus  maximus,  short 
external  rotators  of  hip-joint,  peronei,  extensors 
of  toes  and  flexors  of  ankle ;  second  sacral,  gastroc- 
nemius, soleus,  long  flexors  of  toes  and  extensors 
of  the  ankle-joint  and  muscles  of  the  sole. 


Part  VI— THE   SPINE 


CHAPTER  XXIV 

The  vertebral  column  combines  in  a  remarkable 
way  many  very  different  and  complicated  func- 
tions. It  acts  as  the  central  pillar  of  the  body, 
and  as  the  column  that  supports  the  weight  of 
the  head.  It  connects  the  upper  and  lower  seg- 
ments of  the  trunk.  It  gives  attachments  to  the 
ribs.  It  has  the  property  of  mitigating  the  effects 
of  shocks  that  are  transmitted  from  various  parts 
of  the  body.  It  permits,  to  a  wonderful  degree,  of 
a  number  of  most  complicated  movements;  and, 
lastly,  forms  a  solid  tube  for  the  reception  of 
the  spinal  cord. 

It  owes  much  of  its  elasticity,  and  of  its  power 
of  breaking  up  divers  forces  communicated  to  it, 
to  its  curves.  Of  the  four  curves,  two,  the  dorsal 
and  sacral,  are  primary  and  are  due  to  the  forma- 
tion of  the  thoracic  and  pelvic  cavities,  depending 
mainly  upon  the  shape  of  the  bones.  The  other 
two,  the  cervical  and  lumbar,  are  compensatory 
curves,  and  depend  mainly  upon  the  shape  of  the 
intervertebral  discs.  The  dorsal  and  sacral 
curves  appear  in  foetal  life ;  the  lumbar  and  cervi- 
cal curves  appear  after  birth,  and  depend  on  the 
assumption  of  the  erect  position.  The  infant's 
spine  appears  straight.  The  only  marked  curve 
seen  in  the  back  of  the  young  child  is  a  general 
curving  of  the  column  backwards,  a  kyphosis. 
When  the  infant  is  first  encouraged  to  sit  erect, 
this  is  the  outline  assumed  by  the  spine,  and  in 

600 


Chap.  XXIV]  THE    SPINE  601 

some  weakly  children,  and  especially  in  those 
afflicted  with  rickets,  this  curvature  is  often  very 
pronounced.  The  discs  are  twenty-three  in  num- 
ber and  make  up  nearly  one-fourth  of  the  entire 
length  of  the  spine.  If  the  discs  be  removed, 
and  the  vertebrae  be  articulated  in  the  dry  state, 
the  cervical  and  lumbar  convexities  almost  dis- 
appear, and  the  column  tends  to  present  one  great 
curvature,  the  concavity  of  which  is  forwards,  and 
the  most  marked  part  of  which  corresponds  to 
a  point  just  below  the  middle  of  the  dorsal  region. 
This  somewhat  resembles  the  curve  seen  in  the 
spines  of  the  aged,  and  in  such  individuals  it  may 
be  to  no  small  extent  due  to  the  shrinking  of  the 
intervertebral  discs. 

It  is  by  means  of  the  discs  that  the  movements 
of  the  spine  are  in  the  main  permitted,  and  it  will 
be  found  that  they  are  most  developed  in  regions 
where  most  movement  is  allowed.  They  act  also 
as  springs  in  giving  elasticity  to  the  column,  and 
in  economising  muscular  action,  while  at  the  same 
time  they  play  the  part  of  buffers  in  modifying 
the  effect  of  shocks  transmitted  along  the  spine. 

Although  the  motion  permitted  between  any 
two  individual  vertebrae  is  not  extensive,  yet  the 
degree  of  movement  capable  of  being  exercised 
in  the  column  as  a  whole  is  considerable.  While 
lateral  movements  and  those  of  flexion  and  ex- 
tension are  restricted  in  the  dorsal  region,  those 
of  rotation  are  free ;  hence  scoliosis  of  the  spine 
is  most  marked  in  this  region.  Movements  from 
back  to  front  and  from  side  to  side  are  freest  in 
the  cervical,  dorso-lumbar,  and  lumbar  regions. 
From  a  surgical  point  of  view  the  weakest  part 
of  the  spinal  column  is  between  the  ninth  dorsal 
and  third  lumbar  vertebrae.  Here  side-to-side  and 
back-to-front  movements  occur  most  freely ;  above 
this  region  the  spine  is  supported  by  the  thorax ; 
below  the  intervertebral  discs  are  larger  and 
stronger,  and  the  supporting  ligaments  and 
muscles  better  developed. 

It  is  impossible  to  insist  too  strongly  on  the 


602  SURGICAL   APPLIED    ANATOMY      [Part  VI 

fact  that  the  muscles  of  the  back  and  trunk 
are  the  sole  agents  in  maintaining   the    spine 

erect.  The  minute  they  are  thrown  out  of  action 
the  spinal  column  loses  its  rigidity  and  collapses. 
All  four  groups  of  muscles  which  act  on  the  spine 
are  concerned  :  the  extensors  (erector  spinas) ; 
the  flexors  (rectus  abdominis,  longus  colli,  psoas) ; 
the  lateral  flexors  (erector  spinas,  quadratus  lum- 
borum,  internal  and  external  oblique,  intercos- 
tals,  and  levatores  costarum);  rotators  (external 
and  internal  oblique,  multifidus  spinas,  semi- 
spinalis,  intercostals,  and  levatores  costarum). 
By  these  muscles  the  vertebras  are  maintained 
balanced  on  their  intervertebral  discs,  one  above 
the  other.  The  ligaments  are  slack,  and  the  sur- 
faces of  the  articular  processes  are  in  only  light 
contact.  When  the  muscles  approach  exhaustion, 
owing  to  Drolonged  maintenance  of  the  erect  pos- 
ture, partial  relief  may  be  obtained  by  allowing 
a  certain  degree  of  rotation  and  lateral  flexion 
to  take  place.  Thereby  the  articular  processes  are 
brought  into  firm  contact,  the  ligaments  become 
somewhat  tightened,  and  a  certain  degree  of  pas- 
sive support  is  obtained.  In  this  manner  the  con- 
dition of  scoliosis  is  produced. 

Scoliosis.  —  In  very  few  people  do  the  spines 
of  the  vertebras  lie  in  a  perfectly  straight  line 
down  the  back.  There  is  commonly  a  slight  de- 
gree of  lateral  curvature.  If  the  pelvis  be  tilted 
laterally,  as  when  the  limbs  are  unequal  in  length, 
a  compensatory  lateral  curve  is  produced.  In 
scoliosis,  lateral  curvature  is  combined  with  a 
rotation  of  the  vertebras,  the  spinous  processes 
turning  to  one  side  of  the  median  line  and  the 
bodies  to  the  opposite.  It  is  a  disease  of  ado- 
lescents, due  to  a  weakness  of  the  spinal  muscles, 
which  are  unable  to  maintain  the  vertebras 
in  the  position  necessary  for  the  erect  posture. 
Each  vertebra  is  provided  with  three  levers,  a 
posterior  (the  spinous  process)  and  two  lateral 
(the  transverse  processes  and  attached  ribs).  The 
erector  spinas  acts  on  the  lateral  levers  ;   the  mul- 


Chap.  XXIV]  THE    SPINE  603 

tifidus  spinse  and  muscles  for  the  upper  ex- 
tremity on  the  posterior.  It  is  through  training 
these  muscles  by  suitable  exercises  that  the  ver- 
tebrae can  be  restored  to,  and  maintained  in,  their 
normal  positions. 

Sprains  of  the  vertebral  column. — The 
many  joints  and  ligaments  of  the  part,  and  the 
varied  and  violent  movements  to  which  it  may  be 
exposed,  render  it  very  liable  to  be  the  seat  of 
sprains.  These  injuries,  however,  cannot  reach 
any  great  magnitude,  for  so  closely  are  the  in- 
dividual vertebrae  articulated,  that_  any  force 
severe  enough  to  produce  other  than  slight  tearing 
of  the  ligaments  will  tend  to  cause  a  fracture  or 
dislocation  of  the  bones. 

Sprains  are  most  commonly  met  with  in  the 
cervical  and  lumbar  segments  of  the  spine.  This 
localisation  is  due  to  the  mobility  of  those  parts, 
and  to  their  tendency  to  diffuse  any  violence 
transmitted  to  them,  and  so  to  render  it  more 
general.  For  it  is  to  be  noted  that  the  more 
localised  an  injury,  the  more  likely  it  is  to  pro- 
duce a  fracture  or  dislocation  rather  than  a 
sprain. 

In  the  cervical  region,  also,  the  tendency  to 
sprain  is  increased  by  the  near  articulation  of  the 
column  with  the  head,  and  the  possibility  of  _  any 
violence  applied  to  the  skull  being  transmitted 
to  the  spine. 

Sprains  of  the  spine  are  not  apt  to  be  asso- 
ciated with  the  external  evidences  of  ecchymosis, 
since  between  the  skin  and  the  column  there  inter- 
vene not  only  many  layers  of  muscles,  but  also 
dense  expansions  of  fascia. 

It  has  already  been  pointed  out  that  sprains  in 
the  loin,  produced  by  severe  bending  forwards 
of  the  column,  may  be  associated  with  some 
damage  to  the  kidney  and  consequent  hsematuria 
(p.   410). 

A  sprained  back  is  often  the  seat  of  a  con- 
siderable degree  of  pain  and  stiffness,  that  per- 
sists long  after  the  immediate  effects  of  the  lesion 


604  SURGICAL   APPLIED    ANATOMY    [Part  VI 

must  have  passed  away.  Such  a  condition  may  be 
understood  by  noticing  that  the  column  presents  a 
vast  number  of  separate  articulations,  each  pro- 
vided with  cartilage,  synovial  membrane,  and 
capsular  ligaments.  These  joints  have  no  quali- 
ties that  exempt  them  from  the  common  evils  in- 
cident to  sprains  of  more  superficial  articula- 
tions; and  there  is  little  doubt  that  the  long-felt 
pain  and  inconvenience  often  depend  upon  some 
synovitis  of  the  vertebral  joints.  In  a  few  cases 
this  synovitis  has  gone  on  to  suppuration,  and  in 
one  instance  at  least  the  pus  so  formed  found  its' 
way  into  the  spinal  canal  and  induced  some  mis- 
chief in  the  cord. 

Fractures  and  dislocations  of  the  spine.— 
The  effects  of  violence  applied  to  the  column  are 
much  diminished  by  the  general  elasticity  of  the 
spine,  by  its  curves,  and  by  the  circumstance  that 
it  is  composed  of  a  number  of  separate  segments. 
Each  vertebra  meets  the  one  immediately  above  or 
below  it  at  three  points  of  contact,  the  body  and 
the  two  articulating  processes.  The  bodies  are 
separated  by  the  inter-vertebral  disc,  which  acts 
as  an  excellent  spring  or  buffer  in  modifying  the 
effects  of  violence.  The  articulating  processes  are 
more  or  less  wedge-shaped,  the  thin  edge  of  one 
being  applied  to  the  base  of  the  other.  When  a 
force  is  applied  to  the  column  that  tends  to  com- 
press the  vertebrae  together,  the  bases  of  the  two 
wedges  are  brought  into  more  and  more  close  rela- 
tion, and  thus  an  increasing  resistance  is  offered 
to  the  compressing  power. 

The  parts  of  the  spine  most  liable  to  injury  are 
(1)  the  atlanto-axial ;  (2)  the  cervico-dorsal ;  and  (3) 
the  dorso-lumbar.  In  the  atlanto-axial  region  the 
parts  not  only  enjoy  a  very  considerable  degree  of 
movement  but  are  very  directly  influenced  by 
many  forms  of  violence  applied  to  the  head.  In 
the  two  other  regions  it  will  be  noted  that  a 
flexible  part  of  the  spine  joins  a  comparatively 
rigid  segment  of  it,  and  thus  violence  applied  to 
the  column  in  either  of  these  districts  is  apt  to  be 


Chap.  XXIV]  THE    SPINE  605 

concentrated  rather  than  diffused.  The  sternum 
and  ribs  act  as  a  splint  to  the  dorsal  part  of  the 
column.  The  mechanism  is  in  a  way  illustrated 
by  the  circumstance  that  a  fishing-rod  when  it 
snaps  commonlv  breaks  near  a  joint,  that  is  to 
say,  at  a  spot  where  a  flexible  segment  of  the  rod 
meets  a  less  elastic  portion.  In  the  dorso-lumbar 
region,  moreover,  the  vertebrae,  although  they 
have  to  support  almost  as  much  weight  as  have 
those  of  the  lumbar  region  proper,  are  yet  dispro- 
portionately small  in  size.  Being  placed,  also, 
near  the  middle  of  the  column,  they  can  be  in- 
fluenced on  all  sides  by  a  powerful  amount  of 
leverage.  The  gravity  of  all  injuries  to  the  spine 
depends  upon  the  risk  of  damage  to  the  cord  en- 
closed in  the  column.  Apart  from  this  complica- 
tion, fractures  and  dislocations  in  this  region  are 
apt  to  do  well,  and  if  the  patient  survive,  the 
former  lesions  nearly  always  heal  readily. 

The  position  of  the  cord  within  the  vertebral 
canal  and  the  arrangement  of  its  membranes  are 
such  that  it  presents  many  facilities  for  escaping 
injury  from  violence.  These  will  be  dealt  with 
subsequently  in  speaking  of  the  cord  itself.  <  It 
may,  however,  be  noted  here  that  the  construction 
of  the  vertebrae,  and  their  relation  to  one  another, 
are  of  a  character  to  afford  much  protection  to  the 
cord,  even  in  cases  where  they  themselves  are  ex- 
tensively damaged.  "  Being  lodged  in  the  centre 
of  the  column,  it .  (the  cord)  occupies  neutral 
ground  to  forces  which  might  cause  fracture.  For 
it  is  a  law  in  mechanics  that  when  a  beam,  as  of 
timber,  is  exposed  to  breakage,  and  the  force  does 
not  exceed  the  limits  of  the  strength  of  the 
material,  one  division  resists  compression, 
another  laceration  of  the  particles,  while  the 
third,  between  the  two,  is  in  a  negative  condi- 
tion." (Jacobson,  Holmes's  "  System.")  Now,  it 
happens  that  fractures  of  the  spine  are  most  often 
due  to  violence  that  bends  the  column  forwards. 
The  anterior  segment,  in  such  a  case,  will  be  sub- 
ject to  compression,   the   posterior  to  laceration, 


606  SUEGICAL    APPLIED    ANATOMY     [Part  VI 

and  the  intermediate  portion  will  be  in  a  neutral 
condition.  When  the  spine  is  examined,  it  will 
be  found  that  its  anterior  part,  composed  of  the 
large  cancellous  bodies,  is  excellently  adapted  to 
resist  the  effects  of  compression,  while  its  pos- 
terior parts,  composed  of  slighter  and  more  com- 
pact bones  and  surrounded  by  many  strong  liga- 
ments, are  well  arranged  to  resist  the  effects  of  a 
tearing  force.  The  spinal  cord,  situated  between 
these  two  divisions,  occupies  the  position  of  least 
danger. 

The  vertebrae  may  be  fractured  without  being 
dislocated,  but  a  dislocation  without  a  fracture  is 
rarely  possible. 

It  would  appear,  indeed,  that  a  luxation  of  the 
spine,  with  no  fracture  of  the  bone,  cannot  occur 
in  either  the  dorsal  or  lumbar  regions.  Mr. 
Jacobson,  in  the  essay  above  referred  to,  writes  : 
"I  believe  I  am  correct  in  stating  that  there  is 
no  case  recorded,  and  thoroughly  verified,  in 
recent  years,  of  dislocation  of  the  lumbar  or  dor- 
sal vertebrae  unaccompanied  with  any  fracture  of 
the  body,  transverse  or  articular  processes."  Dis- 
location without  fracture  has  been  met  with  in 
the  cervical  spine,  although  even  there,  if  we 
except  the  first  two  vertebrae,  it  is  very  rare. 
When  it  occurs  it  most  often  involves  the  fifth 
vertebra,  which,  with  the  rest  of  the  column  above 
it,  is  displaced  forwards  and  downwards.  Luxa- 
tions in  other  directions  have  been  noted,  but 
they  are  extremely  uncommon.  The  possibility  of 
luxation  in  the  cervical  region  without  disloca- 
tion is  explained  by  the  small  size  of  the  vertebral 
bodies,  the  obliquity  of  their  articular  processes, 
and  the  relatively  slight  opposition  they  offer  to 
displacement  when  compared  with  like  processes 
in  the  other  parts  of  the  column.  The  luxation  is 
usually  bilateral  and  incomplete,  and  the  result  of 
a  forcible  bending  of  the  head  and  upper  part  of 
the  spine  forwards  and  downwards.  When 
situated  high  up  the  displacement  may  be  appre- 
ciated by  an  examination  of  the  part  through  the 


Chap.  XXIV]  THE    SPINE  607 

pharynx.  In  the  complete  bilateral  dislocation 
the  cord  is  usually  hopelessly  crushed.  These 
luxations  have  been  reduced  by  forcible  extension, 
although  the  circumstances  under  which  such  a 
procedure  is  advisable  are  neither  frequent  nor 
very  distinctly  marked. 

Since,  in  severe  injuries,  dislocation  and  frac- 
ture are  so  usually  associated,  it  is  common  to 
deal  with  these  lesions  under  the  title  of  "  frac- 
ture-dislocation. ' ' 

Fracture-dislocation  may  be  due  to  (l)  in- 
direct, or  (2)  direct  violence.  (1).  The  injuries 
from  indirect  violence  are  by  far  the  more  com- 
mon. They  are  due  to  a  violent  bending  of  the 
head,  or  of  the  spine  above  the  seat  of  lesion,  for- 
wards and  downwards.  Thus,  the  cervical  spine 
has  been  more  than  once  broken  by  a  "header  " 
into  shallow  water ;  while  the  dorsal  vertebrae 
have  been  fractured  and  displaced  by  the  acute 
bending  of  the  column  produced  by  a  heavy  sack 
falling  upon  the  back  of  the  neck. 

This  form  of  injury  is  most  commonly  met  with 
in  the  cervical  and  upper  dorsal  regions.  These 
parts  of  the  column  possess  great  mobility,  the 
bodies  that  compose  them  are  not  large,  and  are 
influenced  by  violence  applied  to  the  head.  In  a 
well-marked  case  there  is  some  crushing  of  the 
vertebrae  involved,  and  the  usual  deformity  de- 
pends upon  the  sliding  of  the  centrum  above 
downwards  and  forwards  upon  the  centrum  below. 
Complete  displacement  of  any  two  vertebrae  from 
one  another  is  prevented  by  a  locking  of  the  pos- 
terior processes.  In  some  cases  the  luxation  is 
complete,  a  condition  that  is  least  frequently  met 
with  in  the  lumbar  spine. 

In  the  cervical  and  dorsal  regions,  the  parts, 
after  the  dislocation,  may  often  be  returned  to 
their  normal  position  ;  but  in  the  loins  this  re- 
placement is  usually  impossible,  owing  to  the  lock- 
ing of  the  large  and  powerful  articular  processes. 
In  the  neck  the  laminae  and  spines  may  be  frac- 
tured,   while    the    articulating    processes,    being 


608  SURGICAL    APPLIED    ANATOMY    [Part  VI 

broad  and  nearly  horizontal,  usually  escape,  even 
when  there  is  much  displacement  of  the  parts.  In 
the  dorsal  spine  the  laminae  and  articular  pro- 
cesses are  always  torn  when  displacement  occurs. 
In  the  lumbar  region  the  articular  processes 
usually  escape  fracture,  although  they  are  vio- 
lently torn  asunder.  In  all  cases  there  is  more  or 
less  laceration  of  the  intervertebral  discs,  the 
supraspinous,  interspinous,  and  capsular  liga- 
ments are  torn,  as  are  also  the  ligamenta  subflava. 
When  the  bodies  are  much  crushed  and  displaced 
the  anterior  and  posterior  common  ligaments  are 
commonly  ruptured. 

(2).  In  the  fracture-dislocations  due  to  direct 
violence  the  lesion  may  be  at  any  part  of  the 
spine.  Some  form  of  direct  violence  is  applied 
to  the  back,  and  the  column  tends  to  become  bent 
backwards  at  the  spot  struck.  In  the  previous 
class  of  injuries  it  will  be  noted  that  the  anterior 
segments  of  the  vertebras  suffer  compression,  while 
the  posterior  suffer  from  the  effects  of  laceration 
and  a  tearing  asunder  of  their  parts.  In  lesions 
due  to  direct  violence  the  circumstances  of  the  in- 
jury are  reversed,  the  posterior  segments  tend  to 
be  crushed  together,  while  the  bodies  on  the  front 
of  the  spine  are  separated. 

Much  displacement  is  very  rarely  met  with  in 
this  form  of  accident.  To  produce  separation  of 
the  vertebrae  the  violence  must  be  very  extreme, 
and  as  a  rule  the  force  expends  itself  upon  a 
crushing  of  the  hinder  portions  of  the  spinal  seg- 
ments. It  follows  from  this,  also,  that  injury  to 
the  cord  is  less  common  and  less  severe  in  lesions 
due  to  direct  violence  than  in  those  due  to  indirect 
violence.  In  the  atlanto-axial  region  the  atlas 
and  occipital  bone  have  been  dislocated  from  one 
another  by  direct  violence,  although  the  most  fre- 
quent lesion  is  a  dislocation  of  the  former  for- 
wards upon  the  axis,  a  lesion  usually,  if  not 
always,  associated  with  fracture  of  the  odontoid 
process. 

The  spinous  processes  may  be  broken  off  as  a 


Chap.  XXIV]  THE    SPINE  609 

result  of  well-localised  blows.  The  prominent 
spines  in  the  lower  cervical  region  and  the  long 
processes  of  the  dorsal  tract  of  the  column  are 
those  that  usually  suffer.  The  lumbar  spines  are 
less  frequently  broken,  being  comparatively  small 
and  well  protected  by  the  great  muscles  of  the 
back. 

The  transverse  processes  and  laminae  can 
scarcely  be  fractured  alone. 

In  several  instances  of  fracture-dislocation  and 
of  fracture  alone  the  spine  has  been  trephined,  or 
rather  portions  of  the  laniinse  and  spinous  pro- 
cesses have  been  resected  {laminectomy).  By  this 
means  the  spinal  canal  has  been  freely  opened  up, 
effused  blood  has  been  allowed  to  escape,  and  the 
cord  has  been  freed  from  pressure.  The  laminae 
are  divided  as  near  the  transverse  process  as  pos- 
sible, and  the  tough  ligamenta  subflava  require 
careful  division. 

The  column  is  reached  through  a  median  in- 
cision, and  the  great  muscular  masses  are  cleared 
from  the  spinous  processes  and  laminae  on  either 
side.  The  wound  being  nearly  median,  the  bleed- 
ing is  not  excessive.  The  dorsal  spinal  plexus  of 
veins  lies  along  the  spines  and  over  the  laminae. 
On  the  deep  surface  of  the  laminae  lie  the  pos- 
terior longitudinal  spinal  veins 

This  operation  has  also  been  carried  out  with 
success  in  cases  of  paralysis  due  to  the  pressure 
upon  the  cord  by  displaced  bone  or  inflammatory 
exudations  in  caries  of  the  spine  (Pott's  disease). 
It  has  to  be  noted,  however,  in  the  last  named 
class  of  case,  that  the  condition  exhibits  a  ten- 
dencv  to  spontaneous  cure. 

The  spinal  cord  is  in  the  adult  about  18 
inches  in  length,  and  extends  from  the  lower 
margin  of  the  foramen  magnum  to  the  lower  edge 
of  the  body  of  the  first  lumbar  vertebra.  In  some 
cases  it  ends  at  the  second  lumbar,  and  in  other 
instances  at  the  last  dorsal  vertebra.  It  is  to  be 
noted  also  that  in  flexion  of  the  spine  the  cord  is  a 
little  raised.  When  the  body  is  bent  and  the  arms 
2N 


610 


SUEGICAL   APPLIED    ANATOMY    [Part  VI 


stretched  out  the  lumbar  part  is  raised  10  mm. 
In  the  earlier  months  of  foetal  life  the  medulla 
spinalis  occupies  the  whole  length  of  the  vertebral 
canal,  but  after  the  third  month  the  canal  and 
lumbar  and  sacral  nerves  grow  so  much  faster 
than  does  the  cord  itself,  that  by  the  time  of  birth 
it  reaches  no  farther  than  the  third  lumbar  ver- 
tebra.    It  is  obviously  a  great  advantage,  in  cases 


Spine. 


Fig.  106. — Section  through   spinal   cord,  membranes,  and   spinal   canal. 

a.r.,  at  origin  of  anterior  root;  p.r.,  at  origin  of  posterior  root;  s.p.,  septum 
posticum ;  p.m.,  pia  mater ;  l.d.,  ligamentum  denticulatum.  The  arachnoid 
(arach.),  dura  mater  (dura  ru.),  and  subarachnoid  space  are  shown. 

of  injury,  that  the  spinal  cord  does  not  occupy 
that  part  of  the  vertebral  pillar  which  joins  the 
base  of  the  column,  and  which  permits  not  only 
of  considerable  movement,  but  is  liable  also  to 
frequent  wrenches  and  strains.  It  is  important  to 
recollect  that  although  the  cord  itself  ends  at  the 
spot  indicated,  the  dura  mater,  the  arachnoid, 
and  the  collection  of  cerebro-spinal  fluid  extend 
as  far  as  the  third  piece  of  the  sacrum  (Fig.  107). 
Injuries     inflicted,      therefore,    upon   the   spine   as 


Chap.  XXIV]  THE    SPINE  611 

low  down  as  this  latter  point  may  cause  death  by 
inducing  inflammation  of  the  meninges.  The  cord 
in  the  dorsal  region  measures  about  10  mm.  from 
side  to  side,  and  8  mm.  in  the  antero-posterior 
direction.  The  cervical  enlargement  is  largest 
opposite  the  fifth  or  sixth  cervical  vertebrae,  where 
it  measures  about  13  mm.  from  side  to  side.  The 
greatest  part  of  the  lumbar  enlargement  is  op- 
posite the  twelfth  dorsal  vertebra,  where  its 
lateral  measurement  is  about  12  mm. 

The  spinal  dura  mater  is  a  strong  and  sub- 
stantial membrane,  and  between  it  and  the  walls 
of  the  vertebral  canal  a  considerable  space  exists 
occupied  by  loose  areolar  tissue  and  a  plexus  of 
veins  (Fig.  106).  It  is  tough,  and  may  remain 
undamaged  when  the  cord  is  completely  severed 
by  a  crushing  force.  It  will  be  readily  understood 
that  injury  and  inflammation  of  the  meninges,  as 
results  of  lesions  applied  to  the  spine,  are  much 
less  frequent  than  are  like  complications  after 
injuries  to  the  skull.  The  looseness  of  the  spinal 
dura  mater,  its  freedom  from  any  but  slight  and 
occasional  attachments  to  the  bone,  and  the  space 
around  it  in  which  effusions  can  extend  with  little 
possibility  of  becoming  limited,  will  explain  the 
rarity  in  the  spine  of  those  complications  which 
follow  upon  depressed  bone  and  extravasations  of 
pus  and  blood  in  connection  with  the  dura  mater 
within  the  skull.  The  plexus  of  thin-walled  veins 
that  occupies  the  interval  between  the  theca  and 
the  bones  may  prove  a  source  of  extensive  haemor- 
rhage in  cases  of  injury  to  the  column.  The  blood 
so  poured  out  tends  to  gravitate  to  the  lowest  part 
of  the  canal,  and  when  sufficient  in  quantity 
may  produce  pressure  effects  upon  the  medulla 
spinalis. 

Over  the  arches  at  the  posterior  aspect  of  the 
vertebrae  is  situate  a  plexus  of  vessels  (the  dorsal 
spinal  veins)  that  receives  blood  from  the  muscles 
and  integuments  of  the  back.  These  vessels  com- 
municate through  the  ligamenta  subflava  with  the 
venous  plexuses  within  the  spinal  canal,  and  by 


612 


SURGICAL    APPLIED    ANATOMY    [Part  VI 


means  of  this  communication  inflammation  from 
without  may  be  conducted  to  the  theca  of  the  cord. 
Thus  spinal  meningitis  has  followed  upon  deep 
bed-sores,  and  upon  suppurative  affections 
situated  in  the  immediate  vicinity  of  the  spinal 
laminae. 

Within  the  dura  mater  are  two  spaces,  the  sub- 
dural and  the  subarachnoid,  as  in  the  skull.  The 
arachnoid  is  closely  applied  to  the  dura  mater, 
the  subdural  being  merely  a  potential  space,  while 
the  subarachnoid  is  extensive  and  occupied  by 
cerebro-spinal  fluid  (Fig.  106),  which  surrounds 
the  cord  and  is  continuous  with  the  great  sub- 
arachnoid spaces  at  the  base  of  the  brain  (Fig.  9, 

p.  35).  By  means  of 
this  open  communi- 
cation inflammatory 
affections  may  readily 
spread  from  the  cord 
to  the  brain.  Into 
these  spaces  blood  may 
be  extravasated  in 
cases  of  injury.  In- 
stances have  been  re- 
corded where  the  theca 
has  been  opened  by  a 
wound,  and  the  cere- 
bro-spinal fluid  has 
escaped  in  large  quan- 
tities. The  fluid  nor- 
mally contains  .05  per 
cent,  of  albumen,  but 
if  the  membranes  are 
inflamed  the  percent- 
age is  double  that 
amount.  In  certain 
conditions  the  pres- 
sure of  the  fluid  may 
rise  to  such  an  extent  as  to  cause  death.  In 
normal  conditions  the  fluid  is  absorbed  at  any 
pressure  above  that  of  the  surrounding  veins 
(Hill).      In   the   recumbent  posture  the   pressure 


Roots 


Fig.  107.  —  Vertical  section  of  the 
lower  part  of  the  spinal  column  to 
show  the  position  and  extent  of 
the  subarachnoid  space. 

The  arfowjsnows  the  point  for  lumbar 
puncture. 


Chap.  XXIV]  THE    SPINE  613 

should  support  a  column  of  water  2  inches  high. 
In  disease  it  may  rise  to  ten  times  that  amount. 
The  pressure  may  be  relieved  by  a  lumbar  punc- 
ture, made  by  thrusting  a  needle  8-10  cm.  long 
into  the  subarachnoid  space  in  the  lumbar  region 
of  the  spine.  A  point  is  selected  between  the  third 
and  fourth  lumbar  spines,  exactly  in  the  middle 
line,  because  here  the  interlaminar  spaces  are 
widest  and  the  danger  of  wounding  blood-vessels 
and  nerve-roots  is  less  than  if  a  lateral  point  is 
selected.  The  interlaminar  space  is  much  in- 
creased when  the  spine  is  bent  forwards.  The 
needle  perforates  the  ligamentum  subflavum  be- 
tween the  lamina?.  Convulsions  follow  if  the  pres- 
sure be  reduced  much  below  the  normal.  At  this 
level  the  cord  cannot  be  injured,  but  the  needle 
may  pierce  one  of  th'3  lower  nerve-roots,  giving 
rise  to  twitching  in  some  of  the.  muscles  of  the 
lower  extremity.  The  injection  of  stovaine  or 
allied  substances  into  the  subarachnoid  space  to 
produce  spinal  analgesia  is  performed  at  the  same 
point  as  lumbar  puncture.  The  injection  should 
not  be  made  until  the  cerebro-spinal  fluid  escapes 
freely  from  the  cannula  when  the  needle  is  with- 
drawn, for  unless  this  occurs  the  cannula  is  not 
yet  within  the  subarachnoid  space.  Mr.  Barker 
has  pointed  out  that  the  lowest  part  of  the  sub- 
arachnoid space  when  the  body  is  supine  is  that 
situated  in  the  mid-dorsal  region,  and  that  there- 
fore a  fluid  which  is  of  greater  specific  gravity 
than  that  of  the  cerebro-spinal  fluid  (1.007)  will 
tend,  if  injected  in  the  lumbar  region,  to  gravi- 
tate to  that  part. 

The  position  of  the  cord  is  such  that  it  is  not 
readily  reached  in  incised  and  punctured  wounds. 
The  only  spots  at  which  it  is  easy  of  access  are  the 
intervals  between  the  atlas  and  occiput  and  the 
atlas  and  axis.  Many  cases  have  been  recorded  of 
fatal  wound  of  the  cord  in  these  positions.  Lower 
down  in  the  column  the  medulla  spinalis  may  be 
reached  if  the  wound  have  a  certain  direction. 
Thus   a   case   is   reported   where   a   pointed   body 


614  SURGICAL   APPLIED   ANATOMY    [Part  VI 

entered  the  canal  between  the  ninth  and  tenth 
dorsal  vertebrae,  having  been  introduced  from 
below  upwards. 

Several  examples  of  damage  to  the  cord  by 
sword  or  bayonet  wounds  have  been  put  on  record, 
but  in  most  of  these  instances  the  wound  was 
associated  with  some  fracture  of  the  protecting 
bone. 

The  pia  mater  forms  a  strengthening  sheath 
for  the  cord.  On  it  the  arteries  ramify  before 
entering  to  supply  its  substance.  The  vertebral, 
intercostal,  lumbar,  ilio-lumbar,  and  lateral 
sacral  arteries  send  twigs  along  the  nerve-roots 
to  the  cord. 

Concussion  of  the  cord. — After  certain  in- 
juries to  the  back  a  train  of  symptoms,  usually  of 
a  severe  and  complicated  character,  has  been  de- 
scribed, which  has  been  assigned  to  a  concussion 
or  shaking  of  the  spinal  cord. 

In  these  injuries  it  is  assumed  that,  as  a  result 
of  a  sudden  shock  transmitted  to  it,  the  cord 
undergoes  certain  molecular  changes,  which  lead 
to  a  more  or  less  severe  disturbance  of  its  func- 
tion. The  condition  has  been  compared  to  con- 
cussion of  the  brain,  although  it  must  be  owned 
that  the  symptoms  often  accredited  to  concussion 
of  the  cord  have  a  character  more  complex  than 
those  seen  in  like  lesions  of  the  more  complex 
organ. 

A  great  many  surgeons  are  inclined  to  dispute 
the  existence  of  this  lesion,  or  rather  decline  to 
recognise  the  connection  between  a  certain  train 
of  symptoms  and  a  simple  molecular  disturbance 
of  the  cord.  _  It  is  very  probable  that  in  many  of 
the  reputed  instances  of  cord-concussion  the  symp- 
toms (if  we  except  such  as  are  assumed  and  such 
as  depend  upon  changes  in  the  brain)  are  due  to  a 
more  distinct  damage  to  the  medulla  spinalis,  to 
haemorrhages,  to  pressure,  and  to  other  gross 
changes.  Without  entering  into  any  discussion 
upon  the  subject,  it  may  be  sufficient  to  point  out 
some  of  the  anatomical  ^objections  that  appear  to 


Chap.  XXIV]  THE    SPINE"  615 

oppose  themselves  to  the  common  conception  of 
concussion  of  the  cord.  The  spinal  cord  is  swung 
or  suspended  in  its  bony  canal,  and  is  separated 
from  the  walls  of  that  canal  on  all  sides  by  a  con- 
siderable interval.  It  is,  indeed,  only  lield  in 
position  by  the  nerve  trunks  that  pass  out  from 
it  through' the  intervertebral  foramina,  and  by  its 
connections  with  the  theca.  Above,  it  is  connected 
with  that  part  of  the  brain  that  lies  upon  the 
largest  intracranial  collection  of  the  cerebro- 
spinal fluid  (p.  35),  and  it  would  appear  that 
the  most  violent  movements  possible  of  the  brain 
within  the  skull  could  be  but  very  feebly  communi- 
cated to  the  spinal  cord.  The  cord,  moreover, 
within  its  theca,  is  surrounded  on  all  sides  by  a 
space  occupied  by  cerebro-spinal  fluid.  It  is  diffi- 
cult to  understand,  therefore,  how  a  structure  so 
protected  can  be  so  violently  disturbed  by  a  shock 
received  upon  the  body  as  to  undergo  a  grave  and 
progressive  loss  of  function.  The  cord  is,  indeed, 
somewhat  in  the  position  _  of  a  caterpillar  sus- 
pended by  a  thread  in  a  phial  of  water.  It  would 
probablv  be  difficult  to  permanently  disturb  the 
internal  economy  of  such  an  insect  (even  if  it  had 
a  structure  as  elaborate  as  the  cord)  by  other  than 
violence  that  would  be  comparatively  excessive. 

Coutusioii  and  crushing  of  the  cord.— As 
has  already  been  observed,  the  _  gravity  of  frac- 
tures and  clislocations  of  the  spine  depends  upon 
the  extent  of  the  damage  received  by  the  cord.  In 
these  accidents  it  is  very  usual  for  some_  part  of 
the  injured  verte'brse  to  be  projected  into  the 
spinal  canal,  so  as  to  press  upon  or  actually  crush 
the  delicate  nerve  centre  that  it  contains. 

It  is  needless  to  observe  that  the  cord  is  ex- 
tremelv  soft,  and  thus  it  happens  that  it  may  be 
entirely  broken  up  by  violence  without  the  mem- 
branes being  perceptibly  damaged.  Indeed,  in 
fracture-dislocations  it  is  unusual  for  the  theca 
to  be  torn,  and  it  is  possible  for  the  cord  to  be 
quite  crushed  at  some  one  spot  without  the  corre- 
sponding pia  mater  being  in  any  way  lacerated. 


616  SURGICAL    APPLIED    ANATOMY    [Part  VI 

The   amount  of   damage   inflicted   upon  the  cord 
will  vary,   of  course,   with  the  magnitude  of  the 
accident ;     but,   other  things  being   equal,   it  will 
be  found  to  be  more  severely  injured  in  fracture- 
dislocations  of  the  cervical  and  dorsal  segments 
than  in  like  lesions  in  the  lumbar  spine.     In  the 
atlanto-axial  region  the  amount  of  displacement 
that  follows  upon  luxation  of  the  two  bones  from 
one  another  is  such  that  the  cord  is,   as  a  rule, 
severely  crushed,  and  death  ensues  instantaneously, 
as  is  seen  in  cases  of  death  by  hanging.     In  the 
cervical  and  upper  dorsal  segments  of  the  column 
the  vertebral  bodies  are  small,  the  spine  is  mobile, 
the  fractures  met  with  in  the  parts  are  usually  due 
to  indirect  violence,  and  are  associated  with  much 
displacement.     In  the  lower  dorsal  region,  again, 
the  greater  rigidity  of  the  spine  renders  any  dis- 
placement,  when  it  does  occur,   likely  to  be  con- 
siderable.     In   the   lumbar    region,    on   the   other 
hand,  it  must  be  noted  that  the  cord  only  extends 
to   the   lower   border   of   the   first  vertebra.      The 
bodies  of  the  vertebrae,   also,   in  this  district,   are 
very   large   and   cancellous,    and   can    undergo    a 
severe  amount  of  crushing  without  a  correspond- 
ing degree  of  displacement  being  produced.     The 
part  is  also  well  protected  by  the  large  interverte- 
bral discs,  and  by  the  immense  masses  of  muscle 
that  surround  the  spine  in  the  loins.     Such  por- 
tion also  of  the  spinal  cord  as  extends  into  the 
lumbar  region  is  protected  by  the  many  cords  of 
the  cauda  equina,   which,   by  their  looseness  and 
comparative    toughness,     tend    to    minimise    the 
effects  of  violence. 

The  degree  of  displacement  of  bone  required  to 
produce  pressure  effects  upon  the  cord  is  often 
greater  than  would  be  supposed.  At  post-mortem 
examinations  portions  of  injured  vertebrae  have 
been  found  encroaching  upon  the  spinal  canal  to 
a  considerable  extent  in  cases  where  no  evidences 
of  damage  to  the  cord  existed  during  life.  Dr. 
J.  W.  Ogle  reports  the  case  of  a  man  who,  after 
an  injury  to  the  neck  from  a  fall,   presented  no 


Chap.  XXIV]  THE    SPINE  617 

spinal  symptoms  until  three  days  had  elapsed. 
He  ultimately  became  paralysed,  and  died  thirty- 
bwo  days  after  the  accident.  The  autopsy  revealed 
a  dislocation  forwards  of  the  sixth  cervical  verte- 
bra, of  such  an  extent  that  the  body  below  pro- 
jected at  least  i-  an  inch  into  the  spinal  canal. 

The  remarkable  manner  in  which  the  cord  will 
accommodate  itself  to  a  slowly  progressing  pres- 
sure is  often  well  seen  in  the  results  of  chronic 
bone  disease  in  the  column. 

The  symptoms  due  to  injury  to  the  cord  and  to 
the  nerves  contained  in  the  spinal  canal  will  ob- 
viously depend  upon  the  situation  and  extent  of 
the  lesion.  The  diagnosis  of  the  situation  of  the 
lesion  is  complicated  by  the  relation  the  nerves 
bear  to  the  various  vertebrae,  and  by  the  fact  that 
the  majority  of  the  great  trunks  arise  from  the 
cord  at  a  spot  above  the  point  at  which  they  issue 
from  the  vertebral  canal.  The  two  highest  nerves, 
the  first  and  second  cervical,  pursue  an  almost 
hcrizontal  course  in  their  passage  from  the  cord 
to  their  points  of  exit  from  the  canal.  The  re- 
maining nerves  take  a  more  and  more  oblique 
direction,  until  at  last  the  lowest  nerve  trunks  run 
nearly  vertically  downwards  as  they  pass  to  their 
respective  intervertebral  foramina. 

Points  of  exit. — The  first  cervical  nerve  leaves 
the  canal  above  the  first  cervical  vertebra.  The 
remaining  cervical  trunks  escape  also  above  the 
vertebrae  after  which  they  are  named,  the  eighth 
cervical  nerve  leaving  the  canal  between  the  last 
cervical  and  the  first  dorsal  vertebras.  The  dorsal, 
lumbar,  and  sacral  nerves  have  their  points  of 
exit  below  the  vertebrae  after  which  they  are 
named.  Thus,  the  first  dorsal  nerve  will  pass 
through  the  foramen  between  the  first  and  second 
dorsal  vertebrae,  and  so  on. 

Points  of  Origin  from  the  Corel. 

The  first  cervical  nerve  arises  from  the  cord  opposite  the  interval 

between  the  atlas  and  occijjut. 
The  second  and  third  cervical  nerves  arise  from  the  cord  opposite 

the  axis. 


618  SURGICAL   APPLIED    ANATOMY    [Part  VI 

The  fourth,  fifth,  sixth,  seventh,  and  eighth  cervical  nerves  arise 

from   the  cord   opposite  the  third,  fourth,  fifth,  sixth,  and 

seventh  vertebrae  respectively. 
The  first  four  dorsal  nerves  arise  from  the  cord  opposite  the  discs 

below  the  seventh  cervical  and  the  first,  second,  and  third 

dorsal  vertebra?  respectively. 
The  fifth  and  sixth  dorsal  nerves  arise  from  the  cord  opposite  the 

lower  borders  of  the  fourth  and  fifth  vertebrae. 
The  remaining  six  dorsal  nerves  arise  from  the  cord  opposite  the 

bodies  of  the  sixth,  seventh,  eighth,  ninth,  tenth,  and  eleventh 

vertebrae. 
The  first  three  lumbar  nerves  arise  from  the  cord  opposite  the 

twelfth  dorsal  vertebra. 
The  fourth  lumbar  nerve  arises  from  the  cord  opposite  the  disc 

between  the  twelfth  dorsal  and  first  lumbar  vertebrae. 
The  last  lumbar  nerve,  together  with   the   sacral   and  coccygeal 

nerves,  arises  from  the  cord  opposite  the  first  lumbar  vertebra. 

It  will  be  seen,  therefore,  that  in  noting 
the  symptoms  due  to  crushing  of  the  entire  nerve 
contents  of  the  vertebral  canal  at  a  certain  spot, 
consideration  must  be  taken,  not  only  of  the  effects 
of  damaging  the  medulla  at  that  point,  but  also  of 
the  result  of  lacerating  nerve-trunks  that  may 
issue  there,  although  their  origins  are  above  the 
seat  of  lesion.  The  cord  is  also  very  often  only 
damaged  in  part,  or  it  may  entirely  escape,  while 
one  or  more  nerves  are  crushed  by  the  fractured 
vertebrae  or  by  fragments  of  bone  separated  by 
the  lesion. 

In  fracture-dislocations  the  upper  vertebral 
body,  as  already  stated,  usually  glides  forward, 
with  the  result  that  the  anterior  and  antero- 
lateral parts  of  the  cord  are  brought  into  violent 
contact  with  the  projecting  border  of  the  ver- 
tebra below  the  seat  of  lesion. 

It  is  in  these  parts  of  the  cord  that  the  main 
motor  tracts  run,  and  thus  it  happens  that  motion 
is  more  often  lost  in  the  parts  below  the  site  of 
the  injury  than  is  sensation.  If  there  be  partial 
motor  and  sensory  paralysis,  the  disturbance  of 
the  former  function  is  likely  to  be  in  excess  of 
that  of  the  latter.  In  no  case,  indeed,  does  there 
appear  to  have  been  a  loss  of  sensation  without,  at 
the  same  time,  some  disturbance  in  the  powers  of 


Chap.  XXIV]  THE    SPINE  619 

movement.  If  the  grey  matter  of  the  cord  be  not 
severely  damaged,  reflex  movements  appertaining 
to  that  segment  of  the  cord  can  usually  be  induced 
in  the  paralysed  parts  by  proper  stimulation.  If 
those  reflex  movements  be  lost,  it  may  be  inferred 
that  the  grey  matter  is  broken  up,  and  that  the 
entire  spinal  medulla  has  been  crushed  at  the  seat 
of  lesion. 

The  higher  up  the  fracture  in  the  column  the 
greater  is  the  tendency  for  the  function  of  respira- 
tion to  be  interfered  with.  If  the  lesion  be  at  the 
upper  end  of  the  dorsal  spine,  then  not  only  will 
all  the  abdominal  muscles  be  paralysed,  but  also 
all  the  intercostals.  A  fracture  associated  with 
injury  to  the  cord,  when  above  the  fourth  cervical 
vertebra,  is,  as  a  rule,  instantaneously  fatal.  The 
phrenic  nerve  comes  off  mainly  from  the  fourth 
cervical  nerve,  receiving  contributions  also  from 
the  third  and  fifth.  The  fourth  nerve  issues  just 
above  the  fourth  cervical  vertebra.  If  the  cord 
be  damaged  immediately  below  this  spot,  the 
patient  can  breathe  only  by  means  of  the  dia- 
phragm, and  if  the  lesion  be  so  high  as  to  destroy 
the  main  contribution  to  the  phrenic,  respiration 
of  any  kind  becomes  impossible. 

Certain  disturbances  of  the  act  of  micturition 
are  frequent  in  cases  of  injury  to  the  cord.  The 
reflex  centre  for  this  act  is  lodged  in  the  lumbar 
enlargement.  The  irritation  of  the  vesical  walls, 
produced  by  the  increasing  distension  of  the 
bladder,  provides  the  needful  sensory  impulse. 
This  impulse  is  reflected  to  the  nerves  controlling 
the  bladder  muscles,  and  especially  to  the  detrusor 
urinse,  and  by  their  contraction  the  organ  is 
emptied  (p.  448).  The  action,  however,  can  be 
to  some  extent  inhibited  by  influences  passing 
down  from  the  brain  to  the  lumbar  centre,  and  the 
tendency  to  a  frequent  discharge  of  urine  is  re- 
sisted by  contraction  of  the  sphincter.  When, 
therefore,  any  part  of  the  cord  is  damaged  that 
lies  between  the  lumbar  centre  and  the  brain,  in- 
hibition  can   have   no   effect.      Immediately   after 


620  SURGICAL   APPLIED   ANATOMY    [Part  VI 

the  accident  the  temporary  suspension  of  reflex 
actions  from  shock  produces  some  retention  of 
urine,  and  after  that  the  bladder  empties  itself  at 
frequent  intervals,  the  patient  being  unconscious 
of  the  act  and  unable  to  influence  it. 

If  the  centre  itself  be  damaged  in  the  lumbar 
cord,  the  patient,  after  a  little  retention,  will 
suffer  from  absolute  incontinence ;  and  a  like 
result  will  follow  if  the  nerve  connections  between 
the  cord  and  bladder  below  the  spinal  centre  have 
been  destroyed.  The  principal  nerves  connecting 
the  medulla  spinalis  with  the  bladder  are  the 
third  and  fourth  sacral. 

The  act  of  defsecation  also  is  apt  to  be  dis- 
turbed in  a  like  manner.  Here  there  is,  as  in  the 
previous  case,  a  reflex  centre  in  the  lumbar  en- 
largement, with  motor  and  sensory  nerves  connect- 
ing it  below  with  the  rectum  and  its  muscles ;  and 
also  between  this  centre  and  the  brain  are  tracts, 
but  little  known,  along  which  inhibitory  actions 
can  extend. 

When  the  centre  itself  is  damaged,  or  the  con- 
nection severed  that  unites  it  with  the  viscus,  the 
patient  will  suffer  from  incontinence  of  faeces  and 
will  be  unable  in  any  way  to  control  the  act. 
When  the  cord  is  damaged  at  any  spot  between  the 
centre  and  the  brain,  then  the  act  of  defsecation 
will  be  performed  at  regular  intervals,  without 
either  the  patient  being  conscious  of  the  act  or 
being  capable  of  inhibiting  it. 

In  some  injuries  to  the  cervical  cord  the 
patient  has  suffered  from  severe  vomiting  for  some 
time  after  the  accident,  or  has  exhibited  a  remark- 
able alteration  in  the  action  of  his  heart.  Mr. 
Erichsen,  for  example,  reports  the  case  of  a  man 
who,  after  a  severe  blow  upon  the  cervical  spine, 
continued  to  vomit  daily  for  several  months.  In 
the  other  category,  instances  have  been  recorded 
where  the  pulse  has  sunk  as  low  as  48,  or  even  as 
36  or  20,  after  lesions  to  the  column  in  the  neck. 

These  changes  are  supposed  to  be  due  to  dis- 
turbance of  the  vagus,  and  it  is  further  suggested 


Chap.  XXIV]  THE    SPINE  621 

that  the  morbid  influence  is  conveyed  to  the  vagus 
by  the  spinal  accessory  nerve  with  which  it  is  so 
freely  associated. 

It  should  be  remembered  that  the  spinal  acces- 
sory trunk  has  origin  from  the  cord  as  low  down 
as  the  sixth  or  seventh  cervical  nerves.  Some  de- 
tails concerning  the  position  of  centres  in  the 
spinal  cord,  connected  with  areas  of  skin,  groups 
of  muscles  and  viscera,  have  been  given  already 
when  dealing  with  the  nerve  supplies  of  the  ex- 
tremities  and  abdomen  (see  pp.    337  and  594). 

Spina  bifida,  —  This  term  refers  to  certain 
congenital  malformations  of  the  vertebral  canal 
associated  with  the  protrusion  of  some  of  its  con- 
tents in  the  form  of  a  fluid  tumour.  The  mal- 
formation usually  consists  in  an  absence  of  the 
neural  arches  and  spines  of  certain  of  the  verte- 
brae, and  the  tumour  therefore  projects  pos- 
teriorly. Spina  bifida  is  most  common  in  the 
lumbo-sacral  region,  the  neural  arches  of  the  last 
lumbar  and  of  all  the  sacral  vertebrae  being  ab- 
sent. The  neural  arches  close  first  in  the  dorsal 
and  last  in  the  lumbo-sacral  region.  Next  in  fre- 
quency it  is  found  limited  to  the  sacral  region. 
It  is  rare  elsewhere.  (1)  The  membranes  may 
protrude  alone  (spinal  meningocele).  (2)  The 
membrane  may  protrude  together  with  the  spinal 
cord  and  its  nerves  (meningo-myelocele).  (3) 
The  membranes  may  protrude  with  the  cord,  the 
central  canal  of  which  is  dilated,  so  as  to  form  a 
sac  cavity  (syringo-myocele).    {See  Fig.  107,  p.  612.) 

The  meningo-myelocele  is  the  most  common 
form.  The  first-named  variety  is  rare,  the  last- 
named  very  rare.  When  the  cord  occupies  the  sac 
it  usually  adheres  to  its  posterior  wall,  the  nerves 
running  transversely^  across  the  sac  to  reach  the 
intervertebral  foramina.  When  compressed,  the 
cerebro-spinal  fluid  is  forced  into  the  subarach- 
noid spaces  at  the  base  of  the  brain,  which  is 
forced  upwards  against  the  anterior  fontanelle, 
where  its  impact  may  be  felt.  The  tumour  be- 
comes enlarged   and  tense   when   the  child  cries. 


622  SURGICAL    APPLIED    ANATOMY    [Part  VI 

The  distension  of  the  cerebral  and  spinal  veins 
forces  the  fluid  in  the  direction  of  least  resistance. 

As  might  be  expected,  spina  bifida  is  very  com- 
monly associated  with  some  evidence  of  injury 
to  the  nerves  arising  from  the  lower  part  of  the 
spinal  cord.  The  defect  occurs  at  an  extremely 
early  stage  of  development,  and  hence  part  of 
the  cord  or  of  the  nerves  in  the  region  of  the 
tumour  may  be  absent  or  defectively  developed. 
In  some  cases  the  nerve  affection  takes  the  form 
of  club-foot  of  a  severe  grade.  In  other  instances 
there  is  more  or .  less  complete  paralysis  of  the 
lower  limbs,  bladder,   and  rectum. 

Operations  upon  the  cord.  —  Sir  Victor 
Horsley  and  others  have  cut  down  upon  the 
spine  and  removed  a  tumour  from  the  spinal  cord 
with  perfect  success,  and  with  relief  to  the  symp- 
toms from  which  the  patient  was  suffering.  The 
spinal  canal  has  also  been  exposed  in  certain  cases 
where  callus  in  an  old  fracture  of  the  spine  was 
pressing  upon  the  cord,  or  where  a  small  osseous 
growth  was  encroaching  on  the  canal. 


INDEX 


Abdomen,  blood-vessels  of,  324, 

332,    421 

,  blows  on  the,  326 

,  congenital  deformities  of 

the,  338 

,  fascia  of,  325 

,  lymphatics  of  the,  332 

,  nerves  of,  333,  418 

,  parietes  of,  321,  324,  330, 

353 

,  skin  of  the,  325 

,  surface  anatomy  of  the, 

321 
,  wounds  of  the,  331 

-  Abdominal  belt,"  325 

■ ,  connective        tissue 

and  abscesses,  330 
■   rings,  338,  341 

viscera,  nerve  supply  of, 

337,  418 

■   ,  support  of,  367 

■ .  surface       markings 

of,  364 

Abscess,  alveolar,  136 

,  axillary,  234 

,  cervical,  167 

,  gluteal,  481 

,  hepatic,  399 

,  iliac,  331,  354 

in  antrum,  109 

in  mastoid  cells,  87 

in  the  abdominal 

parietes,  331,  353 

in  the  scalp,  6 

in    the    temporal    fossa, 

8 

,  intercostal,  201 

.  ischio-rectal,  436 

,  lumbar,  353,  357 

,  mammary,  205 

,  mediastinal,  167,  213 

,  orbital,  52 

,  palmar,  300 

,  parotid,  122 

,  pelvic,  428,  431 


Abscess,   perinephritic,  411 

,  perityphlitic,  o85 

,  plantar,  566 

,  popliteal,  528 

,  post-pharyngeal,   153 

,  prostatic,  452 

,  psoas,  355,  489 

,  renal,  411 

,  retroperitoneal,  354 

,  thecal,  303 

Acetabulum,  427,  494, 

,  fractures  of,  427 

Acromio-clavicular  joint,  214, 
227 

,  dislocations  of,  229 

Acromio-thoracic  artery,  216, 
218 

Acromion  process,  fracture  of, 
230 

Addison's  disease,  419 

Adductor  longus  muscle,  486 

■      tubercle,  524 

Adenoids,  153 

Air  in  veins,  189,  237 

■    sac  in  neck,  194 

"  Alderman's  nerve,"  82 

Alveolar  abscess,  136 

Amputation  (see  Arm,  Leg, 
etc.,  amputation  of,  etc.) 

Anal  canal,  470 

triangle,  433 

■ valves,  474 

Angulus  Ludovici,  198 

Anastomoses  between  tribu- 
taries of  superior  and  in- 
ferior venae  cavae,  213,  322 

■   portal  and  systemic 

veins,  360,  422 

Anastomotica  magna,  525 

Aneurism,  aortic,  188,  421 

•,  axillary,  237 

in  the  neck,  188 

■   of    the    posterior    tibial 

artery,  553 

1  popliteal,  530 


623 


624 


SUEGICAL   APPLIED    ANATOMY 


Ankle,  561 

,  fasciae  of,  565. 

joint,  562,  570 

■   ,  amputation  at,  591 

,  disease  of,  5/1 

■   ,  dislocations  at,  572 

,  fractures  about,  572 

,  nerve  supply,  572 

,  sprains  of,  567 

,  surface  anatomy  of,  561 

,  tendons  of,  562 

Annular   ligaments   of   ankle, 
566 

■   of  wrist,  300 

Anterior  crural  nerve,  491,  594 
Anticlinal  spine,  207 
Antrum  of  Highmore,  109 

of  mastoid.  87 

Anus,  434,  474 

imperforate,  475 

Aorta,  abdominal,  324,  420 

thoracic,  188,  211 

Aponeuroses  (see  Fasciae) 
Appendicitis,  385 

Appendix  vermiformis,  382,  385 

,  lymphatics  of,  386 

Aqueous  humour,  69 
Arachnoid,  34,  611 

Arcus  senilis,  58 
Arm,  256 

,  amputation  of,  261 

,  fascia  of,  257 

,  lymphatics  of,  269 

,  nerves  of,  313 

,  skin  of,  256 

■ — — ,  surface  anatomy  of,  255 

Arnold's  nerve,  81 

Arteries     (see     Axillary,     etc., 

and  Blood-vessels) 
Arterio-venous    aneurisms,  53, 

268,  490 
Aryteno-epiglottidean       folds, 

152,  173 
Astragalus,     dislocations     of, 

579 

,  fractures  of,  587 

Atlas,  152 

Atlo-axial    portion    of     spine, 

604 
Attic  of  tympanum..  84,  87 
Auditoi'y  meatus,  external,  79 

— — ,  its  relations,  80 

Auricle  (see  Ear) 

Auricles,    supernumerary,    78, 

194 
Axilla,  217,  233 
,  suspensory    ligament    of. 

234 
Axillary  abscess,  234 


Axillary   artery,  217,  237,  250 

fasciae,  167,  233 

glands,  204,  217,  235 

• nerves,  240 

vein,  236 

Axis,  152 
Azygos  veins,  213 

Bartholin's  glands,  466 

Basal  gangli,  42 

Base  of  skull,  fractures  of,  27 

Basilic  vein,  264 

Biceps  tendon  in  arm,  243,  262 

■    ■    ham,  529 

Bile  duct,  rupture  of  the,  401 

,  relationships  of,  400 

Bladder,  420,  443 

,  cystoscopic    examination 

of,  447 

development  of,  329 

distension  of,  444 

double,  449 

extroversion  of,   338 

fasciculated,  448 

female,  449 

foreign  bodies  in,  449 

found  in  hernias,  445 

male,  443 

mucous      membrane      of 
the,  447 

nerves  of,  448,  476 

of  child,  450 

puncture        of,        above 
pubes,  444 

,  per  rectum,  446 

relations     to     the     peri- 
toneum, 443,  444,  445 

rupture  of  the,  446 

sacculated,  448 
-   stabbed      through      but- 
tock, 486 

,  stone  in  the,  438 

Blood-vessels  of  abdomen,  324, 
332,  421 

of   abdominal   walls,  332 

of  auditory  meatus,  79 

■   of  brain,  44 

■  of  breast,  205 

■  of  buttock,  480,  483 

•  of  eye,  61 

■  of   foot,  563,   569 

of  hand,  295,  304 

of  heel,  591 

■  of  knee.  529 

of  leg,  553 

■  of  nasal  cavities, 

of  neck,  160,  187 

of  orbit,  53 

of  palate,  151 


103 


INDEX 


625 


Blood-vessels  of  pelvis,  433 

of  perineum,  434 

of  pinna,   81 

of  rectum,  472 

of  retina,  62 

of  scalp,  13 

of  spinal  cord,  614 

of  Scarpa's  triangle,  490 

of  spermatic  cord,  465 

of  tympanum,  92 

Bones,  nerve-supply  of,  320 
Brachial  artery.  256,  258,  269 

,  abnormalities       of, 

258 

in  phlebotomy,  264, 

267 

,  ligature  of,  258 

fascia,  256 

plexus,  162,  238,  314 

Brachialis  anticus,  257 
Brain,  33,  42,  44 

■   and  skull  relations,  37 

,  basal  ganglia  of,  42 

,  blood-vessels  of  the,  45 

,  concussion  of  the,  44 

,  convolutions  of,  38 

,  cortex  of,  42 

,  fissures  of,  38 

,  injuries  to,  44 

,  membranes  of,  31 

■ ,  motor  centres  of,  38,  42 

.  surface  relationships  of, 

37 
Branchial  fistulae,  78,  193 
Brasdor's  operation,  187 
Breast  (see  Mamma),  202 
Bregma,  17 

Broca's  convolution,  41 
Bronchi,  174 

,  foreign  bodies  in,  180,  210 

Bronchial    lymphatic    glands, 

185 
Bronchocele,  181 
Brunner's  glands,  379 
Bryant's   method   of   dividing 

the  muscles  of  the  palate, 

151 
Buccal  cavity,  138 

■   in  embryo,  148 

nerve,  117 

Bulla  ethmoidalis,  101 
Bunions,  568 

Bursae  about  the  elbow,  271 

~> foot,  567 

hyoid,  172 

•   ham,  531 

shoulder,  243 

over      the       great       tro- 
chanter, 482 

2   0 


Bursse  over  the  ischial  tuber- 
osity, 483 
knee-joint,  527, 

531 

,  patellar,  527 

,  subacromial,  243 

,  subpsoal,  489 

Buttocks,  478 

arteries    and    nerves    of 

the,  480,  483 

fascia  of,  481 

,  fold  of,  479 

,  surface  anatomy  of,  478 

Caecum,  382,  392 

,  foreign  bodies  in,  384 

,  hernia  of,  384 

in  intestinal  obstruction, 

384 

,  movements  of,  384 

,  opening  of,  394 

-,  position  of,  382 

Caesarian  section,  427 
Oalcaneo-astragaloid  joint,  578 
Oalcaneo-cuboid    articulation, 

580 
Calcaneo-scaphoid      ligament, 

584 
Calcar  femorale,  503 
Canal  of  Nuck,  hernia  in,  346 
Capsule  of  Tenon,  50 
Cardiac  orifice  of  stomach,  368 
Carotid    artery,    86,    156,    160, 

187,  188 

,  aneurism  of,  187 

,  destroyed    by     abs- 
cess, 167 

■  •,  external,  123 

,  ligature  of,  187 

,  sheath  of,  167 

,  wounds  of,  170 

tubercle,  158,  189 

Carpo-metacarpal   joints,  308 
Carpus,  fracture  of,  310 
Castration,  454,  465 
Cataract,  67 

Catheterism      of     Eustachian 
tube,  90 

Of  urethra,  455 

Cavernous  sinus,  33,  54 
Centre  of  gravity  of  an  adult 

body,  426 
Cephalhsematomata,  7 
Cephalic  vein,  219,  264,  267 
Cerebellum,  point  for  trephin- 
ing, 11 

,  lesions  of,  47 

Cerebral  circulation,  36,  44 

localisation,  38,  42 


626 


SURGICAL    APPLIED    ANATOMY 


Cerebrospinal  fluid,  29,  36,  99, 

612 
Cervical  (see  Neck) 

ribs,  169 

sinus,  194 

sympathetic,       paralysis 

of,  55 

Cervico-dorsal   part    of   spine, 

604 
Check  ligaments,  51 
Cheloid,     its     frequent     seat, 

197 
Cholecystectomy,  403 
Oholecystenterostomy,  403 
Cholecystotomy,  402 
Chopart's  operation,  592 
Chorda  tympani,  84,  92 
Choroid,  58 
Ciliary  zone,  65 
Circumcision,  458 
Circumcorneal  zone,  66 
Circumflex     artery,     external, 

rupture  of,  518 

,  internal,  wound  of, 

518 

,  posterior,  218,  241 

■   nerve,  218,  241 

Cirsoid  aneurism,  13 
Cisternal  of  brain,  34 
Clavicle,  214,  219 

,  absence  of,  224 

,  dislocations  of,  226,  229 

,  excision  of,  220 

,  fractures  of,  220 

,  movements  of,  228 

,  ossification  of,  224 

,  relations  of,  218,  223 

Cleft  palate,  147 
Clergyman's  sore  throat,  175 
Club-foot,  581 
Coccygeus,  430 
Coccygodynia,  430 
Coccyx,  430 
Cceliac  axis,  324,  421 
Colectomy,  394 
Colles'  fascia,  437 

fracture,  308 

Coloboma  iridis,  61 
Colon,  387 

,  antiperistalsis  in,  471 

,  ascending,  388 

,  descending,  388,  393 

•,  iliac,  388 

■ ,  malformation  of,  390,  392 

— — ,  operations  on,  394 

,  stricture  of,  388 

,  transverse,  388 

Colotomy,  iliac,  392,  394 
,  lumbar,  388,  392 


Compression  of  brain,  32 

of  cord,  611,  616 

Concussion  of  brain,  44 

of  cord,  614 

Congenital  club-foot,  520 
exomphalos,  328,  338 

fistuhe,  78,  194 

hernia,  328,  338 

hydrocele,  345 

malformations    of    anus 

and  rectum,  475 

malformations    of    blad- 
der, 329,  338 

■   malformations   of  colon, 

391 
malformations   of   penis, 

338 
tumour     of     sterno-mas- 

toid,  164 
Conjunctiva,  74 
Convolutions  of  brain,  motor 

centres  on,  42 

,  relations  of,  37 

Coraco-acromial  arch,  242 
Coraco-clavicular      ligaments, 

221,  228 
Coracoid  process,  216 

,  fracture  of,  231 

Cornea,  56 

Coronal  suture,  18 
Coronoid  process  of  ulna,  264, 
279 

of  mandible,  140 

Corpus  striatum,  42 
Costo-vertebral  ligament,  415 
Coxa  vara,  505 

Cowper's  glands,  466 
Cranial  nerves,  54 
Craniectomy,  30 
Cranio-tabes,  18 
Cranium  (see  Skull) 
Cremaster  muscle,  464    ' 
Cremasteric  artery,  464 

reflex,  464 

Cribriform  plate,  99 
Cricoid  cartilage,  173 
Crico-thyroid  space,  177 
Crucial  ligaments,  536 
Crural  canal,  347 

sheath,  353 

Crutch  paralysis,  259 
Cuboid  bone,  587 
Cuneiform  bone,  inner,  561 
,  ,  dislocation    of 

the,  587 
,  ,  fracture         of 

the,  587 
Cut  throat,  170 
Cystic  duct,  400 


INDEX 


627 


Dartos,  325 

Deltoid  muscle,  240,  255 

region,  215,  240 

tubercle,  214 

Descending    palatine     artery, 

149 
Diploic  veins,  14 
Dislocation    (see    the    several 

bones  and  joints) 
Dorsalis  pedis  artery,  570 
Dorso-lumbar    part    of    spine, 

604 
Drop-wrist,  318 
Duodenal  fossa,  379 
Duodenum,  378 
,  suspensory      muscle     of, 

379 
Duchenne's  palsy,  239 
Dupuytren's  contraction,  298 

■   fracture,  575 

Dura  mater,  31,  611 

Ear,  78 

,  bleeding  from,  in  frac- 
tures of  base  of  skull,  29 

,  blood  supplv  of,  81 

,  coughing,  82 

,  external,  78 

,  hsematomata  of,  81 

,  nerves"  of,  81 

,  ossicles  of,  84,  85 

.  watery    discharge    from, 

29 

,  yawning,  82 

Ectopia  vesicae,  338,  471 

Elbow,  262,  264 

,  bursas  about,  271 

,  dislocations  of  the,  272 

,  fold  of  the.  262 

,  fractures  about,  276 

,  gland  of.  269 

joint,  269 

■   ,  disease  of,  271 

,  sprains  of.  271,  275 

,  ligaments  of,  271 

,  resection  of  the,  280 

,  surface  anatomy   of  the, 

263 

.  veins  about,  267 

Elephantiasis  arabum.  493 
Emissary  veins  of  skull,  13 
.  Emphysema,  surgical,  208 
Encephalocele.  19 
Encysted     hydrocele     of     the 

cord, 345 
Enterectomy,  381 
Enteroraphy,  381 
Enterotomy,  381 
Epicondyles,  277 


Epicritic  sensibility,  117,  319 

Epididymis,  463 

Epiphysis,  lower,  of  femur  in 

excision  of  knee,  548 
,  ,  in  knock-knee,  539 

of   acromion,   separation 

of,  231 

of     clavicle,     separation 

of,  224 

of  coracoid  process,  231 

of  femur,  separation  of, 

500,  505,  548 
of    humerus,     separation 

of,  252,  278 

of  olecranon,  279 

of  pelvis,  separation   of, 

427 

of  radius,  separation  of, 

280,   310 

tibia,  separation  of,  548, 

558 

of  third  phalanx  in  whit- 
low, 304 

of  upper  limb,  320 

Epipteric  bone,  21 
Epispadias,  459 
Epistaxis,  104 

Erb's  palsy,  239,  314 
Erector  spinae,  602 
Estlander's  operation,  201 
Ethmoidal  cells,  101 
Eustachian  catheter,  to  pass, 
91 

tube,  89 

Eversion,  movements  of,  578 
Excision  (see  special  parts) 
External  auditory  meatus,  78 
— —   ,  blood      supply 

of,  81 
,  nerve      supply 

of,  81 

carotid,    bleeding    from, 

189 

pterygoid,  action  of,  132 

Extravasation    of    urine,    324, 

437 
Eye-baH,  48 

,  blood  supply  of  the,  61 

,  dangerous  area  of,  65 

,  nerves  of  the,  63 

Eyelids,  71 

Face,  111 
— ,  development  of,  114 

,  injuries  to,  112 

,  nerves  of,  115 

,  vessels  of,  112 

Facial  artery,  113,  160 

nerve,  86,  124 


628 


STJKGICAL   APPLIED    ANATOMY 


Fallopius,  aqueduct  of,  85 
Fascia,  abdominal,  325 

,  axillary,  233 

,  bicipital,  263,  267 

,  cervical,  164 

,  clavi-pectoral,  233 

,  iliac,  353 

lata,  481,  488,  516 

lumborum,  356 

obturator,  431 

of  arm.  257 

of  buttock,  481 

of  Oolles,  437 

of   deltoid  region,  240 

■   of  foot.  565 

of  leg,  552 

—   of  palm,  298 

of  scalp,  1,  6 

of  Scarpa's  triangle,  488 

■   of  tbigb,  481,  488,  516 

.orbital,  50 

,  palmar,  298 

,  parotid,  122 

,  pectoral,  233 

•,  pelvic,  430 

■,  perineal,  437 

,  popliteal,  528 

,  prevertebral,  166 

,  recto-vesical,  431 

,  temporal,  7 

-,  transversalis,  353 

Femoral  hernia,  347,  352 

point,  340 

vessels,  487,  490,  518,  525 

Femur,  dislocations  of,  506,  544 
,  epiphyses     of,     500,     505, 

548 
,  fractures  of,  502,  504,  518, 

545 

,  neck  of.  502 

Fenestra  ovalis,  85 

rotunda,  85 

Fergusson's  method  of  divid- 
ing the  muscles  of  the 
palate,  150 

Fibula,  550,  556 

.  fractures  of,  558,  573 

Fifth  nerve,  15,  55,  82,  95,  115, 
134 

,  section  of,  117 

Finger,  "  snap,"  301 

,  little,  congenital  con- 
traction of,  301 

,  "  mallet."  508 

Fissure  of  Rolando,  38 

■ ■   Sylvius,  40 

Fissures  of  brain,  38 

,  parietal,  21 

Fistula  at  the  navel,  329 


Fistula  between  the  gall  blad- 
der and  gut,  401 

,  congenital,  78,  193 

,  gastric,  370 

in  ano,  436 

,  lachrymal,  77 

,  salivary,  127 

,  vesico-vaginal,  467 

,  umbilical,  329 

Plat-foot,  583 
Pontana,  spaces  of,  69 
Fontanelle,  sagittal,  21 

,  temporary  occipital,  20 

Fontanelles,  17 
Foot,  abscess  of,  566 

,  amputations  of,  591 

— — ,  arches  of,  576 

,  blood-vessels  bf,  563,  569 

,  chief  joints  of,  578 

,  dislocations  of,  579,  586 

,  fasciae  of,  565 

,  fractures  of,  586 

,  imprints  of,  587 

,  integuments  of.  564 

,  lymphatics  of,  570 

,  movements  of,  578 

,  nerves  of,  564 

,  surface  anatomy  of,  561 

,  synovial   membranes   of, 

589 

,  the,  517,  561,  564 

Foramen    caecum    of    tongue, 

145 

of  Majendie,  36 

of  Monro,  36 

Foramen  ovale,  surface  mark- 
ing of.  117 

Forearm,  282 

,  amputation  of  the,  288 

,  bones  of  the,  284 

,  fractures  of  the,  286 

,  luxations  of  the,  273 

-.  surface  anatomy  of  the, 

282 

-,  vessels  of  the,  283 

Fossa  duodeno-jejunalis,  379 

,  ischio-reetal,  435 

,  nasal,  100 

of  Rosenmuller,  91 

-,  subclavicular,  216 

■   in  region  of  caecum,  386 

Fracture      (see     the      several 

bones) 
Fraenum  linguae,  141 
Frontal  sinus,  106 

.  infundibulum        of, 

101,  107 

Gall  bladder,  396,  400 


INDEX 


G29 


Gall  bladder,  arteries  of,   400 
— ,  fundus  of,  396 
-,  nerve  supply  of,  401 
-,  operations  on,  402 
-,  rupture  of  the,  401 
—   obstructed   by  mov- 
able kidney,  364 

-,  veins  of,  400 
-   stones,  354,  400 
Gasserian  ganglion  affected  by 
abscess      spreading     from 
parotid,  123 

,  position  of,  13 

,  removal  of,  119 

Gastrectomy,  373 
Gastrocnemius  muscle,  551 

,  rupture  of  the,  553 

Gastro-enterostomy,  374 
Gastroplication,  374 
Gastrostomy,  372 
Gastrotomy,  372 
Generative  organs,  female,  466 

■   ,  male,  458 

Genito-crural  nerve,  464,  491 
Genu-valgum,  539 
Gimbernat's  ligament,  349 
Gladiolus,  196 

Glans  penis,  459 
Glaucoma,  58,  70 
Glottis,  159,  174 
Gluteal  abscess,  481 

■    aneurisms,  483 

artery,  480,  483 

bursae,  482 

fascia,  480 

fold,  479 

region,  478 

Gluteus  maximus,  482 

■   ,  rupture  of,  482 

Great  toe,  dislocation  of,  588 
Groin,  lymphatics  of,  491 

,  pains  referred  to,  420 

,  region  of,  486 

Gubernaculum  testis,  343 
Gullet  (see  Oesophagus) 
Gums,  140 

Gustatory  nerve,  Moore's 
method  of  dividing  the, 
140 

Hsematomata  of  scalp,  7 

on  septum  nasi,  100 

on  the  pinna,  81 

Haemorrhage  from  choroid,  59 
from  fraenum  linguae,  141 

from  intercostal   vessels, 

201 

from  tongue,  142 

from  tonsil,  156 


f   Haemorrhage  in  lithotomy,  440 
I    ■   into  vitreous,  63 

in  tracheotomy,  179 

,  meningeal,  32 

Haemorrhoidal      vessels      and 

nerves,  436,  472 
Haemothorax,  208 
Hallux  rigidus,  589 

valgus,  589 

Hammer  toe,  589 
Hamstring  muscles,  524,  529 
Hand,  290 

-,  amputation  of,  313 

,  blood-vessels  and  lym- 
phatics of,  295,  304 

,  dislocations  of,  311 

■,  fasciae  of,  298 

,  surface  anatomy  of,  292 

,  synovial  sheaths  of,  302 

Hanging,  mode  of  death  from, 
616 

Hard  palate,  149 

Hare-lip,  148 

Heart,  210 

,  its  relation  to  the  sur- 
face, 210 

,  wounds  of,  211 

Heel,  blood-vessels  of,  591 

,  integuments  of,  591 

Helicoidal  fractures  of 
Leriche,  520,  557 

Hernia,  congenital,  329,  339, 
342 

,  diaphragmatic,  351 

,  direct,  341 

■ ,  encysted,  345 

,  fatty,  327 

,  femoral,  347 

,  infantile,  345 

,  inguinal,  338,  345 

into  the  funicular  pro- 
cess, 345 

-,  ischio-rectal,  351 

,  lumbar,  351 

,  mesenteric,  380 

,  obturator,  350 

,  omental,  360 

,  perineal,  351 

,  pudendal,  351 

,  rare  forms  of,  351 

,  retroperitoneal,   380 

,  sciatic,  351 

,  umbilical,  329,  351 

,  vaginal,  467 

Hernial  sacs,  338,  352 
Herniotomy,  347 
Hesselbach's  triangle,  341 
Hiatus  semilunaris,  101 
Hip,  dislocations  of,  507 


630 


SURGICAL    APPLIED    ANATOMY 


Hip  joint,  479,  494 

,  amputation  at  the, 

513 

■ ,  congenital  disloca- 
tions of,  506 

,  disease,  495,  500 

■   ,  fractures  about,  502 

,  movements  of,  495 

,  nerve  supply,  500 

•   ,  region  of  the,  478 

Holden's  line,  486 
Hottentot  Venus,  480 
Human  tails,  429 
Humerus,  dislocations  of,  215, 

241 

,  fractures  of,  251,  259,  276 

■ ,  of,  non-union  after, 

260 
Hunter's  canal,  518 
Hyaloid  membrane,  70 

artery,  70 

Hydrencephalocele,  19 
Hydrocele,  345,  462 

of  the  neck,  194 

Hydrocephalus,  17,  37 

Hyoid  bone,  159,  172 

■ ,    accessory      glands 

about,  182 

,  fracture  of,  172 

Hypertrophy  of  the  prostate, 

451 
Hypogastric  line,  366 
Hypoglossal  nerve,  124,  143 
Hypopyon,  69 
Hypospadias,  459 
Hypothenar  eminence,  292 
Hysterical  hip,  501 
■   knee,  501 

Ileo-csecal  fossae,  386 

intussusception,  386 

region,  382 

sphincter,  384 

•   valve,  386 

Ileo-colic  intussusception,  386 
Ileum  (see  Intestine,  small) 
Iliac  abscess,  354 

colotomy,  394 

— —   fascia,  353 
Ilio-psoas  muscle,  353,  489 
Ilio-tibial  band,  482,  524 
Indirect  hernia,.  338 
Infantile  hernia,  345 
Inferior  caval  point,  211 
Inferior  dental  nerve,  dividing 

the,  116,  130 

maxilla,   deformities    of, 

134 

,  dislocations  of,  132 


Inferior   maxilla,   excision  of, 

133 

■  ,  fracture  of,  129 

,  subluxation  of  the, 

133 
thyroid  veins,  179 

vena  cava,  421 

Infraorbital  foramen,  115 

artery,  115 

■   nerve,  115 

Infundibulo-pelvic      ligament 

469 
Inguinal  canal,  338,  341 

■   colotomy,  392 

■   glands,  487,  491 

hernia,  338,  341 

Innominate  artery,  187 

bone,  426 

Intercostal  artery,  201 

-  spaces,  200 
Intercosto-humeral  nerve,  205 
Internal      cutaneous      nerve, 

268 

mammary  artery,  202 

Interparietal  bone,  21 
Interscapulo-thoracic      ampu- 
tation, 232 

Intersigmoid  fossa,  390 

Intervertebral  discs,  601 

Intestine,  large,  387 

,  operations  on,  381 

-,  stricture  of,  378 

resection  of,  381 
small,  374 

,  diverticula  of,  377 

,  injury  of,  376 

■,  length  of,  374 

,  operations  on,  381 

,  position  of,  375 

Intestinal  anastomoses,  381 

Intussusception,  386 

Iridectomy,  61 

Iris,  56,  58 

Iritis,  60 

Ischial     spine     as     guide     to 
ureter,  418 

Ischio-rectal  abscess,  436 

■   fossa,  435 

hernia,  351 

Isthmus  of  the  thyroid,  182 

,      division 

of,  179,  182 

Jaws       (see       Inferior       and 

Superior  maxilla) 
Jejunum  (see  Intestine,  small) 
Joints,    surgical   classification 

of  the,  241 
Jugular  vein,  86,  160,  191 


INDEX 


631 


Keloid  (see  Cheloid) 
Kidney,  408 

,  abnormalities  of,  413 

,  abscess  of,  411 

,  hilum  of,  408,  416 

,  borse-shoe,  413 

,  its  relations,  408 

,  its  support.  412 

• ,  movable,  411 

,  nerve  supply  of,  412 

•.  operations  on,  415 

,  pelvis  of,  410,  417 

,  rupture  of,  410 

,  vessels,    point    of    origin 

of,  324 
Knee,  blood  supply  of  the,  527 

,  bursa?  about,  527,  531 

,  dislocations  of  the,  544 

,  fractures  about,  545 

,  integuments  of,  525 

joint,  532 

,  amputation  through, 

548 

,  derangement  of,  538 

,  disease  of,  536 

,  excision  of  the,  547 

.  region  of,  523 

,  surface  anatomy  of  the, 

523 
Knock-knee,  539 
Kraske's  operation,  473 
Kyphosis,  196,  601 

Labia  majora.  466 
Labyrinth  of  ear,  92 
Lachrymal  abscess,  76 

apparatus,  75 

gland,   75 

sac,  75 

Lacuna  magna,   urethral,  458 
Lambda.  17 
Lambdoid  suture,  17 
Lamina  cribrosa,  59,  71 

fusca,  59 

suprachoroidta,  59 

Laminectomy,  609 
Laryngotomy,  177 
Larynx.  173 

,  excision  of,  176 

,  foreign  bodies  in,   180 

,  fracture  of,  173 

,  lymphatics  of,  176 

,  mucous  membrane  of,  175 

Lateral  lithotomy,  435 

sinus,  position  of,  10,  33 

ventricles,  42 

Leg,  550 

,  amputation  of,  558 

,  fasciae  of,  552 


Leg,  fractures  of,  556 

,  rickets     affecting     bones 

of,  558 

,  skin  of,  551 

,  surface  anatomy  of,  550 

,  vessels  of,  553 

Lens,  66 

,  artery  to  the,  70 

Levator  ani,  430,  435 

,  relation    to    fistula 

in  ano,  436 

palati,  150 

palpebral,  72 

Ligamentum  patellae,  523,  536 

pectinatum  iridis,  69 

Lighterman's  bottom,  483 
Liuea  alba,   322,  327 

- — -    semilunaris,   322 
Linsrual  artery,  142,  160 

nerve,  139.  140,  142 

tonsil,  143 

Lipomata    in    deltoid    region, 
240 

in  Scarpa's  triangle,  488 

on  the  buttock,  479 

,  rare  on  face,  112 

Lips,  137 

Lisfranc's  amputation,  593 
Litholapaxy.  438 
Lithotomy,  lateral,   438 

,  ,  in  children,  441 

,  ,  parts      divided     in, 

440 

,  median,  441 

,  suprapubic,  443 

Littre's  operation,  390 
Liver,  395 

,  abscesses  of,  399 

,  fixation  of,  397 

,  nerve  supply  of,  420 

,  operations  on,  399 

in  pyaemia,  399 

,  ptosis  of,  397 

,  relations  of,  395 

,  Kiedel's  lobe,  397 

,  ruptures  of,  397 

,  wounds  of,  398 

Lockjaw,  135 
Longitudinal  sinus,  33 
Lordosis  in  hip  disease,  497 
Lower  limb,  length  of,  520 

,  lymphatics  of,  492 

■   ,  nerve      supply      of, 

594 
Lumbar  colectomy,  394 

colotomy,  392 

fascia,  356 

glands,   492 

■   hernia,  351 


632 


SURGICAL   APPLIED    ANATOMY 


Lumbar  puncture,  613 

region,  356 

spine,  603 

. ,  injuries  to,  603,  616 

Lung,  206 

and    secondary    deposits, 

210 

cavities,  drainage  of,  210 

hernia  of,  208 

in  neck,  168,  206 

,  relations  of,   to   surface, 

206 

,  rupture  of,  208 

-,  wounds  of,  207,  208 

Luschka's  tonsil,  91,  153 
Lymphangioma     cavernosum, 

145 
Lymphatic  glands  and  vessels 

(see  each  region) 

Macroglossia,  145 
Malar  bone,  120 

,  fracture  of,  120 

Malleoli,  561 

,  fractures   of,  in   disloca- 
tions of  the  foot,  572 
Mamma,  202 

,  arteries  of,  205 

,  cancer  of,  203 

,  capsule  of,  203 

,  development  of,  203 

— —   in  groin,  488 

,  lymphatics  of,  203,  235 

,  nerves  of,  203 

Mammary  abscess,  205 
Manubrium,  196 
Mastication,  muscles  of,  135 
Mastoid  antrum,  87 
■   cells,  89 

,  perforation  of,  89 

Maxillae     (see     Inferior     and 

Superior) 
Meatus,  the  auditory,  79 
Meatuses  of  nose,  100 
Meckel's  diverticulum,  329,  377 

ganglion,  115 

Median  basilic  vein,  264,  267 
Median  cephalic  vein,  264 
Median  lithotomy,  441 

nerve,  281,  284,  318 

Mediastina,  213 

,  abscess  of,  167,  213 

Mediotarsal  joint,  580 

,  amputation  at,  592 

Meibomian  glands,  73 
Membrana  tympani,  83 
Membranous  urethra.  456 
Meningeal  artery,  9,  32 

haemorrhage,  32 


Meninges  of  brain,  31 

,  spinal  cord,  611 

Meningitis  from  abscess  in 
the  ear,  80,  86,  89,  99 

(spinal)    from    bed-sores, 

612 

Meningocele,  19,  96,  99,  621 
Mesenteric  arteries,  324,  421 

hernia,  380 

holes,  362 

Mesentery,  360 

,  length  of,  346,  361 

,  prolapse  of,  361 

Mesocolic  hernia,  380 
Mesocolon,  388 
Metacarpo-phalangeal  joint  of 

thumb,  dislocations  at,  312 
Metacarpus,  fracture  of,  310 
Metatarsal  bone  of  great  toe, 

amputation  of,  594 

bones,  fractures   of   the, 

587 

Metatarso-phalangeal  articu- 
lations, 562 

joint  of  great  toe,  dis- 
location at,  588 

Middle  meningeal  artery,  32 

,  trephining  for, 

9,  10 

Mid-epigastric  point,  323,  365 

Mid-hypogastric  point,  366 

Miner's  elbow,  271 

Monro's  point,  366 

Morgagni,  columns  of,  474 

Motor  centres  on  the  cortex, 
38 

paralysis   in   injuries   to 

cord,  618 

Mouth,  138 

Mucous  polyp  of  nose,  103 

Miiller's  muscle,  56 

Muscles,  functional  classifica- 
tion, 307 

Musculo-cutaneous  nerve  of 
arm,  268 

Musculo-spiral  nerve,  259,  281, 
318 

Myxcedema,  183 

Nails,  297 

Nares,  anterior,  96 

,  posterior,  97 

Nasal  bones,  96 

-,  fracture  of,  96 

-  cavity,  96 

-  cavity  of  child,  98 

-  cavities,   lymphatics     of, 
105 

-   ,  blood-vessels  of,  103 


INDEX 


633 


Nasal   cavities,    nerve    supply 
of,  104 

douche,  99 

duct,  77,  100 

.   fossae,  100 

mucous  membrane,  102 

■   polypus,  103 

sinuses,  105 

Neck,  158 

,  abscess  of,  167 

,  fascia?  of,  164 

,  fistula?  of,  193 

,  great  vessels  of,  160,  171 

,  hydrocele  of,  194 

— — ,  integuments  of,   162 

,  lung  in,  168,  206 

,  lymphatic  glands  of,  191 

,  middle  line  of,  159 

,  nerves  of,  161 

,  ribs  in,  169 

,  side  of,  159 

,  surface  anatomy  of,  158 

,  wounds  of,  170 

Nelaton's  line,  479 
Nephrectomy,  415 
Nephro-lithotomy,  415 
Nephroraphy,  415 
Nephrotomy.  415 
Nerve  stretching,  484 

supply     of     lower    limb, 

594 

of  upper  limb,  313 

Nerves       (see      the       various 

regions) 
,  division      of      (see      the 

various  trunks) 
of  the  spinal  cord,  their 

points  of  exit,  616 
,  results  of  section  of,  117, 

318 
,  of  anastomosis,  125, 

598 

to  viscera,  337 

Neuralgia,  facial,  115 

of  scalp,  14 

Nipple,  203 

Nipples,  supernumerary,  205 
Nose,  94 

,  cartilaginous      part      of, 

95 

Obturator    artery   (abnormal) 
349 

hernia,  350 

nerve,  501,  596 

or     thyroid     dislocation, 

507,  512 

Occipital  artery,   161 

bone  at  birth,  19 


Occipital  bone,  necrosis  of, 
causing  wasting  of  tongue, 
143 

glands,  191 

Odontoid  process,  608 
CEsophagus,  184,  367 

,  cancer  of,  186 

-,  foreign  bodies  in,  185 

,  malformations  of,  186 

,  nerve  supply  of,  186 

,  relations  of,  185 

Olecranon,  265 

,  fractures  of,  279 

-,  ossification  of,  279 

Omega  loop  of  colon,  389 
Omental  hernia,  360 

sac,  360 

Omentum,  great,  359 
Omo-hyoid,  160 
Ophthalmia,  sympathetic,  66 
Optic  disc,  67,  71 

nerve,  67 

neuritis,  67 

thalamus,  42 

Ora  serrata,  67 

Orbicularis  palpebrarum,  72 

Orbit,  48 

,  abscess  of,  52 

-,  arteries  of,  53 

-,  dimensions  of,  48 

,  fasciae  of,  50 

,  fracture  of,  48 

,  muscles  of,  53 

,  nerves  of,  53 

,  pulsating  tumours  of,  53 

,  relations  of,  49 

Os  calcis,  dislocations  of  the, 
579 

■-,  fractures      of      the, 

586 

epactal,  21 

innominatum,    427 

magnum,   dislocation  of, 

311 

Ovario-pelvic  ligament,  469 
Ovary,  468 

,  influence  of,  468 

,  nerves  of,  468 

Pacinian  bodies  in  the  foot.  561 

in  the  hand,  296 

Palate,  147 

,  cleft,  147 

,  development  of,  147 

,  hard,  149 

,  soft,  149 

Palmar  (see  Hand) 
Palmaris  longus  tendon,  290 
Pampiniform  plexus,  465 


634 


SUKGICAL   APPLIED    ANATOMY 


Pancreas,  406 
Pancreatic  cysts,  408 

■   ducts,  406 

Paracentesis    of    the    pericar- 
dium, 212 

of  the  thorax,  201 

of  the  tympanum,  87 

of      the      ventricles      of 

brain,  42 

Paralysis   in    spinal   injuries, 
618 

of  anterior  crural  nerve, 

594 

■   of  brachial  plexus,  314 

of    cervical  sympathetic, 

55 
■   of  Erb,  239,  314 

of       external      popliteal 

nerve,  596 

of  facial,   125 

of  fourth  nerve,  54 

of    great    sciatic    nerve, 

598 

of       internal       popliteal 

nerve,  596 

of  median  nerve,  318 

of    musculo-spiral  nerve, 

259,  318 

of  obturator  nerve,  596 

of  orbital  nerves,  54 

of  sixth  nerve,  54 

of  ulnar  nerve,  318 

Parasinoids,  33 

Parietal     bone,    relationships 
of,  21,  41 

fissures,  21 

Parieto-occipital  fissure,  41 
Parathyroid  bodies,  183 
Parotid  abscess,  122 

fascia,  122,  166 

■   gland,  122 

■   lymphatic  glands,  126 

nerve  supply,  123 

region,  120 

structures,  125 

tumour,   126 

Patella,  523,  541 

,  development  of,  543 

,  dislocation  of,  543 

,  fractures  of,  541 

Patellar  ligament,  523,  536 

■   bursa,  527 

Pectoral  glands,  204 
Pelvic' arch,  424 

cellulitis,  431 

colon,  389 

fascia,  430 

symphysis,  427 

Pelvis,  424 


Pelvis,  floor  of,  430 

,  fractures  of,  426 

,  mechanism  of,  424 

,  nerves  of,  433,  475 

,  vessels  of,  433 

Penile  urethra,  457 
Penis,  458 

■ ,  lymphatics  of,  459 

,  malformations  of,  459 

Perforating  ulcer,  565 
Pericardium,  tapping  of,  211, 

212 
Pericranium,  5 
Perineal  hernia,  351 
Perinephritic  abscess,  411 
Perineum,  depth  of,  435 

■ ■,  fasciae  of,  437 

,  male,  433 

,  nerves  of,  475 

,  vessels  of,  434 

Perirenal  capsule,  411 
Peritoneum,  358 

,  fossae  of,  341,  352,  386 

,  watersheds  of,  362 

Perityphlitis,  384 
Peroneal  artery,  551 

muscles,   562,  567,  568 

nerve,  529 

tubercle,  562 

Petit's  triangle,  323,  356 
Petro-squamous  suture,  86 
Phantom  tumour,  329 
Pharyngeal  pouch,  187 

recess,  91 

Pharynx,  151 

,  excision  of,  154 

,  foreign  bodies  in,  151 

,  mucous     membrane     of, 

91,  153 
— — ,  relations  of,  152 
Phrenic  nerve,  162,  420 
Pigeon  breast,  195 
Piles,  472 

Pinna  (see  Ear),  78 
Pirogoff's  amputation,  591 
Plantar  (see  Foot) 
Plantaris  tendon,  rupture  of, 

553 
Platysma  myoides,  162 
Pleura,  207 

,  wounds  of,  207 

— ,  to  last  rib,  415 
Pneumatocele,  89 
Pneumothorax,  207 
Politzer's  method  of  inflating 

the  middle  ear,  90 
Pollock's   method   of   dividing 

the  muscles  of  the  palate, 

150 


INDEX 


635 


Popliteal  abscess,  528 

bursas,  531 

fascia,  528 

glands,  531 

-  nerves,  480,  529,  596 

space,  528 

vessels,  525,  529,  548,  551 

Portal  vein,  360,  421 
Post-nasal  growths,  153 
Pott's    disease    of    spine,    196, 

609 

— —  ,  operations  in,  609 

•   fracture,  575 

Poupart's  ligament,  486 
Preputial  ocelli,  460 
Processus  vaginalis,  338,  343 
Profunda  arteries  in  arm,  258 

•    femoris,  487,  490 

Prolapsus  ani,  469 
Pronation,  movement  of,  285 
Prostate,  441,  450 

,  abscess  of,  452 

,  capsule  of,  452 

,  commissures  of,  451 

,  hypertrophy  of,  451 

,  lobes  of,  451 

,  lymphatics  of,  454 

,  nerves  of,  452 

,  sheath  of,  452 

Prostatectomy,  452,  453 
Prostatic  plexus  of  veins,  454 
Protopathic     sensibility,     117, 

319 
Psoas  abscess,  355 

muscle,   353,  489 

Pterion,  40 
Pterygo-mandibular  ligament, 

140 
Ptosis,  54 
Pubic  spine,  322 
Pudendal  hernia,  351,  466 
Pudic  artery,  480 
Pulmonary  artery,  209 
Puncta  lachrymalia,  75 
Pupillary  membrane,  61 
Pylorus,  368,  370 

,  hypertrophy  of,  371 

,  resection  of  the,  373 

Quadriceps  of  thigh,  517 

Radial  artery,  283,  306 

nerve,    strength    of    the, 

484 

Radio-humeral  joint,  265 
Radius,    dislocations    of    the, 

274,  276 
,  fractures  of  the,  280,  286, 

290 


Radius,  surface  markings,  283 
Ranula,  139 
Rectocele,  467 
Recto-vaginal  fistula,  467 
Recto-vesical  pouch,  446,  469 
Rectum,  389,  435,  469 

,  attachments  of  the,  472 

-,  effects    of    distension    of, 

470 
,  foreign  bodies  in,  470 

—  of  infant,  390 

,  introduction      of      hand 

into,  471 

,  lymphatics  of,  473 

,  malformations  of,  391 

mucous     membrane     of, 

472 

,  nerves  of,  474 

,  serous  membrane  of,  469 

,  valves  of,  472 

,  vessels  of,  472 

Rectus  abdominis  muscle,  327, 

329 
Recurrent      laryngeal     nerve, 

176,  184 
Referred    pain,    135,    318,    337, 

420,  555 
Reflex  contracture,  330 
Renal  abscess,  411 
Resection     (see     the     various 

parts) 
Respiration  in  fracture  of  the 

spine,  619 
Retina,  67 

,  central  artery  of,  62 

Retroperitoneal  hernia,  380 
Retropubic  space,  445 
Rhinoplasty,   256 
Rhinoscopy,  96,  97 
Ribs,  198 

,  cervical,  169 

,  excision  of,  201 

,  fractures  of,  199 

,  twelfth,  323,  415 

Rickets,  effect  of,  on  pelvis,  425 

-,  ribs,  200 

skull,    18 
tibia,    558 
Rider's  bone,  489 

■    sprains,  489 

Riedel's  lobe,  397 
Rima  glottidis,  159,  174 
Rivini,  notch  of,  84 
Rolando,  fissure  of,  38 
Rosenmuller,  fossa  of,  91 
Rouge's  operation,  96 

Sacro-coccygeal  joint,  429 

tumours,  429 


636 


SUEGICAL   APPLIED    ANATOMY 


Sacro  -  iliac       synchondrosis, 

428 
Sacrum,  424 

,  dislocation  of  the,  429 

Sagittal  fontanelle,  21 
Salivary  fistuhe,  126 
Santorini,  duct  of,  406 
Saphenous  opening,  347,  487 

veins,  487,  491,  516,  525 

Sartorius  muscle,  486,  489 
Scalene  muscles,  160 
Scalp,  ahscess  of,  6 

,  dangerous  area  of,  3 

,  fatty  tissue  in,  2 

,  hsematoma  of,  7 

,  its  mobility,  3 

,  lymphatics  of,  16,  192 

,  nerves  of,  13,  15,  16 

,  neuralgia  of,  14 

,  sebaceous  tumours  of,  2 

,  sutures  in  wounds  of,  3 

,  suppuration  in  the,  6 

,  temporal  region  of,  7 

,  vascularity  of  the,  4 

,  vessels  of,  13 

wounds,  4 

Scaphoid  bone,  dislocation  of 

the,  587 
Scapula,  216,  229 

,  excision  of,  232 

,  fractures  of,  230,  231,  232 

,  "  winging  "  of,  230 

Scarpa's  triangle,  486 

,  fascia  of,  488 

,  glands  of,  487 

— —  ,  vessels  of,  487,  490 

Schlemm,  canal  of,  69 
Sciatic  artery,  480,  483 

dislocation,  507 

nerve,  great,  480,  483,  598 

Sciatica,  484 

Sclerotic,  58 
Scoliosis,   196,  602 
Scrotum,  460 

■   and  oedema,  461 

,  application  of  leeches  to 

the,  461 

,  lymphatics  of,  463 

,  subcutaneous     tissue    of 

the,  461 
Semilunar  cartilages  of  knee, 

dislocation  of  the,  538 
Semimembranosus  tendon, 

524,  529 
Sensori-motor  areas  of  brain, 

38,  42 
Septum  of  nose,  100 
Sesamoids  of  hallux,  588 
Shoulder,  214 


Shoulder,  bursse  about,  243 

,  dislocation    of    the,    245 

248,  249,  250 

— — ,  fractures  about  the,  251 

joint,  241 

■  ,  amputation  at  the, 

253 

disease  of  the,  244 

,  surface  anatomy  of,  214 

■ tip  pain  from  liver  ail- 
ments, 420 

Sibson's  fascia,  168 

Sigaultean  operation,  427 

Sigmoid  flexure,  389 

Sinus,  cervical,  194 

,  lateral,  10 

pocularis,  455 

,  superior  longitudinal,  33 

,  sphenoidal,  108 

Sinuses  of  skull  (venous),  32 

(air)  of  skull,  105 

Skull,  17 

,  abnormalities  of,  19 

,  deformities  of,  19,  23 

,  development  of,  18 

,  emissary  veins  of,  13 

,  fractures  of,  22,  26 

,  necrosis  of,  5,  21 

of  infant,  17,  23,  30 

,  pillars  of,  24 

,  soft  parts  covering,  1 

,  sutures  of,  16,  29 

,  thickness  of,  30 

,  trephining  the,  9 

,  venous  tumours  of,  16 

Soft  palate,  149 
Solar  plexus,  419 
Soleus,  553 
Spermatic  artery,  464 

cord,  464 

■   plexus  of  veins,  465 

Sphenoidal  sinus,  108 
Sphincter  ani,  435,  471 
Spina  bifida,  621  [230 
Spinal    accessory    nerve,    162, 
anaesthesia,  613 

-  cord,  545,  609 
blood  supply  of,  614 
concussion  of,  614 

— ,  contusion  and  crush- 
ing of,  615 

-  ,  loss  of  motion   due 

to  injury  of  the,  618 

,  sensation 

due  to  injury  of  the,  618 
operations  on,  622 

-  ,  wounds  of,  612,  613 

-  injuries  and  defsecation, 
620 


INDEX 


637 


Spinal  injuries  and  micturi- 
tion, 619 

and  respiration,  619 

and  vomiting,  620 

meninges,  611 

meningitis,  611 

nerves,   disti'ibution,  317, 

598 

,  points  of  origin,  616 

Spine,  600 

,  curves  of,  196,  600 

,  fractures  and  disloca- 
tions of,  604 

,  how     maintained     erect, 

602 

,  scoliosis  of,  196 

,  sprains  of,  603 

,  trephining  the,  609 

Spinous  processes,  fracture 
of,  608 

Splay  foot,  583 

Spleen,  403 

,  capsule  of  the,  405 

,  dislocation  of,  404 

,  enlarged,  404 

,  extirpation  of  the,  405 

,  injuries  to  the,  404 

,  relations  of,  404 

,  rupture  of,  404 

Stenson's  duct,  126 

Sterno-clavicular  joint,  224 

,  disease  of,    225 

,  dislocations  of,  226 

,  movements  of.  224 

Sterno-ensiform  line,   365 

— —   point,  323,   365 
Sterno-manubrial  joint,   197 
Sterno-mastoid  muscle,  159,  163 
Sterno-xiphoid  joint,  197 
Sternum,  196 

,  fractures   of,   197 

,  holes  in,  198 

,  separation    of    segments 

of,  197 

,  trephining  the,  198 

Stomach,  367 

,  displacement  of,  366 

,  fistulse  of,  370 

,  foreign  bodies  in,  371 

.  functional    divisions    of, 

369 

,  lymphatics  of,  372 

,  operations  on,  373 

,  ptosis  of,  366 

,  relations  of,  367 

,  wounds  of  the,  370 

Strabismus.  53,  54 
Stylo-maxillary  ligament,  166 
Subacromial  bursa,  240 


Subarachnoid  space,  34,  612 
Subastragaloid       amputation, 

594 
,  dislocations  of  the  foot, 

579 

joint,  578 

Subclavian  artery,  161,  187 

vein,  161,  219 

Subclavicular  fossa,  216 
Subclavius  muscle,  219 
Subdural  space,  34,  612 
Sublingual  bursa  mucosa,  139 

gland,  138 

papilla,  138 

Submaxillary  gland,  139 

lymphatic     glands,      144, 

191 

Subperitoneal    connective    tis- 
sue of  the  abdomen,  330 
Superficial  cervical  glands,  191 
Superior  maxilla,  127 

■ -,  antrum  of,  109 

— ,  cleft  of,  147 

excision  of  the,  128 
fractures  of,  127 
necrosis  of,   128 
-   thyroid  artery,  159 

vena  cava,  213 

Supination,  movement  of,  285 
Supinator  longus,  266 
Supraclavicular  nerves,  219 
Supracondyloid  process,  259 
Suprahyoid  glands,  191 
Supraorbital  foramen,  115 
Suprapubic  lithotomy,  443 
Suspensory    ligament   of    eye- 
ball. 51 

Sustentaculum  tali,  562 

■ ,  fracture  of,  586 

Sutures  of  skull,  17,  20,  29 

,  closure  of,  24 

,  position  of,   17 

.  relations       of, 

to  brain,  37 
.  relations  of,  to 

surface,   17 

,  separation    of, 

29 

Sylvius,  fissure  of,  40 
Symblepharon,  75 
Syme's  amputation,  591 
Sympathetic  ophthalmia,  66 
Symphysis  of  pelvis,  427 
Synostosis  of  skull,  24 
Synovial  cavities  of  the  foot, 

589 

■    ■   of  the  hand,  311 

membranes,   relationship 

to  tendons,  304 


63S 


SURGICAL   APPLIED    ANATOMY 


Synovial  membranes  of  knee, 
536 

sheaths  in  the  hand,  302 

of  ankle,  567 

Synovitis,   acute,   in   the  hip- 
joint,  495 

,  ,  in  the  knee,  477 

Tabatiere  anatomique,  295 
Tagliacozzi's  operation,  256 
Talipes  calcaneus,  581 
■    cavus,  565 

equinus,  581 

and    the  plantar  fascia, 

565 

,  mixed  forms  of,  582 

valgus,  582 

varus,  581 

Talma-Morrison  operation,  422 
Tarsal    bones,    fractures    and 

dislocations  of,  586 

,  locations  of,  586 

,  ossification  of,  588 

ligaments  of  orbit,  76 

plate,  72 

Tarsectomy,  583 
Tarso-metatarsal  joint,   593 
Tarsus  (see  Foot) 

Taxis,  349 
Teeth,  135 

,  wisdom,  136 

Tegmen  tympani,  position  of, 

11 
Temporal  abscess,  8 

convolutions,  40,  41 

•   fascia,  7 

fossa,  7 

Temporo-maxillary      articula- 
tion, 131 

,  dislocations  at,  132 

,  movements  of,  132 

Tendo  Achillis,  562,  568 

oculi,  76 

Tendon,    suture    and    anasto- 
mosis of,  569 
Tenon's  capsule,  50 
Tenotomy  at  ankle,  568 
Tensor  palati,  150 
Testicle,  343,  462 

,  descent  of,  343,  345 

,  inversion  of,  463 

,  investments  of,  462 

— ,  nerves  of,  463,  477 

,  torsion  of,  462 

,  tunic  of,  463 

,  vessels  of,  465 

Thecal  abscess,  303 
Thenar  eminence,  292 
Thigh,  515 


Thigh,  amputation  of  the,  521 

,  fasciae  of,  516 

,  fractures  of,  518 

,  integuments  of,  516 

,  muscles  of,  517 

,  surface  anatomy  of,  515 

Thoracic  duct,  193,  213,  220,  422 
Thoracoplasty,  201 
Thorax,  195 

,  deformities  of,  196 

,  paracentesis  of,  201 

,  viscera  of,  206 

,  walls  of,  195 

,  wounds  of,  207 

Thumb,  amputation  of  the,  313 

,  dislocation  of,  312 

,  movements  of,  320 

Thymus,  179 
Thyro-glossal  duct,  182 
Thyroid  body,  159,  181 

,  accessory  glands  of, 

145,  182 

,  development  of,  182 

,  excision  of,  183 

■ ,  lymphatics  of,  183 

in  tracheotomy,  179 

cartilage,  159,  173 

,  nerves  of,  183 

Thyroidea  ima  artery,  158, 184 

Thyrotomy,  176 

Tibia  and  fibula,  fractures  of, 

556 

,  fractures  of,  546,  558 

•   in  rickets,  558 

,  ossification  of,  547,  548 

,  shaft  of,  its  strength,  556 

,  upper  end  of,  546 

Tibial  vessels,  551,  553 
Tibialis  anticus  muscle,  550 
Tongue,  141 
,  accessory   glands    about, 

145 

•,  dermoid  cyst  of,  145 

,  blood  supply  of,  142 

,  epithelium  of,  142 

,  excision  of,  146 

,  lymphatics  of,  144 

,  mucous  cysts  of,  142 

,  nerve  supply  of,  142 

Tongue-tie,  141 
Tonsil,  154 

,  bleeding  from,  156 

,  foreign  body  in,  156 

,  hypertrophy  of,  154 

(  and  deafness,  154 

,  lingual,  143 

,  lymphatics,  155 

,  Luschka's,  91,  153 

,  pharyngeal,  91,  153 


INDEX 


639 


Trachea,  159,  173,  177,  210 
,  foreign    bodies    in,     180, 

210 
Tracheotomy,  177 
Transpyloric  plane,  366 
Transversalis  fascia,  353 
Transverse     cervical     artery, 

161 
■   colon,  388 

process  of  the  atlas,  158 

of       the       cervical 

vertebrae,  158 
Trapezium,  292 
Trendelenburg's         operation, 

429 
Trephining,  9,  609 
,  for  intracranial  abscess, 

10 
Triangular    ligament    of    the 

urethra,  386,  436 
Trigone,  447 
Tubera  ischii,  453,  479 
Tunica  abdominalis,  325 
albuginea,  463 

vaginalis,  338,  462 

Turbinate  body,  103 

— —   processes,  102 
Tympanum,  85 

,  blood  supply  of,  92 

,  lymphatics  of,  92 

Ulna,  dislocation  of  the,  273 

,  fracture  of  the,  286 

,  surface  markings  of,  283 

Ulnar  artery,,  283 

■    nerve,  256,  269,  281,  319 

vein  in  venesection,  265, 

267 

Umbilical  fistula,  329 

hernia,  310,  328 

line,  366 

Umbilicus,  fibrous  ring  of,  327 

,  position  of,  322 

,  vessels  of,  328 

Umbo  of  membrana  tympani, 
84 

Urachus,  329,  341 

Ureter,  416,  449 

,  and      regurgitation      of 

urine,  449 

-,  distension  of,  417,  449 

,  resection  of,  418 

,  relationships  of,  416,  450 

,  radiographic  examina- 
tion of,  417 

,  rupture  of,  417 

Urethra,  female,  458 

,  male,  421,  454 

,  ,  curve  of,  454 


Urethra,    male,    membranous, 

438,  454 
,  mucous     membrane     of, 

457 

,  narrowest  parts  of,  457 

,  penile,  455,  457 

,  prostatic,  454,  456 

,  rupture  of  the,  458 

Urethral  triangle,  433,  436 
Uterus,  467 

,  arteries  of,  468 

,  lymphatics  of,  468 

Vagina,  467 

Vaginal  cystocele,  467 

process     of     peritoneum, 

338,  343 

Valsalva's  method  of  inflating 

the  middle  ear,  90 
Varicocele,  465 

Varicose  veins,  465,  472,  491,  554 
Vas  aberrans,  258 

■   deferens,  464 

.  ,  section  of,  454,  464 

Vater,  ampulla  of,  401 
Veins  (see  various  parts) 

,  air  in,  189 

,  emissary  of  skull,  13 

of  diploe,  13 

,  valves  in,  191 

Venesection  at  the  elbow,  267 
Venous  sinuses,  32 

tumours  of  skull,  16 

Ventricles  of  brain,  36,  42 
Vermiform  appendix,  382 
Vertebra,  caries  of,  357 

prominens,  158 

Vertebral  artery,  189 

column,  600 

— — ,  sprains  of,  603 

Vesico-vaginal  fistula,   467 
Visceral  nerves,  337 

supports,  367 

Visceroptosis,  364 
Vitello-intestinal  duct,  329,  377 
Vitreous  humour,  69,  70 
Vocal  cords,  174 

Volvulus       of      the       sigmoid 

fiexure,  390 
Vulva,  466 

Wardrop's  operation,  188 
Weaver's  bottom,   483 
Wharton's  duct,  139 
White  line  at  anus,  474 

in  the  pelvic  fascia, 

430 

Whitlow,  303 
Winged  scapula,  230 


640 


SURGICAL   APPLIED    ANATOMY 


Wirsung,  duct  of,  406 
Wormian  bones,  21 
Wrist,  290 
joint,  291 

,  amputations    at,  313 

,  dislocations  at,  311 

,  fractures  about,  308 


Wrist  joint,  movements  at,  307 

,  surface  anatomy  of  the, 

290 
Wry  neck,  163 

Zygoma,  fracture  of,  12 

as  guide  to  structures,  12 


Printed  by  Cassell  &  Company,  Ltd.,  La  Belle  Sauvaoe,  London,  TC.C. 

20.12.07 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C2B(23B)M100 

551 


T72 
1907 


Treves 


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